317005900-1-22-2025-59-AS-KMKY-DD72TU-20250122164119

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 317005900
Report Date: 01/22/2025
Date Signed: 01/22/2025 04:41:26 PM

Document Has Been Signed on 01/22/2025 04:41 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME:	MEADOW OAKS OF ROSEVILLE		FACILITY NUMBER:	317005900
ADMINISTRATOR/ DIRECTOR:	JESSICA SANDERS		FACILITY TYPE:	740
ADDRESS:	930 OAK RIDGE RD		TELEPHONE:	(916) 774-0200
CITY:	ROSEVILLE	STATE: CA	ZIP CODE:	95661
CAPACITY: 108	TOTAL ENROLLED CHILDREN: 0	CENSUS: 70	DATE:	01/22/2025
TYPE OF VISIT:	Case Management - Incident	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	03:15 PM
MET WITH:	Jessica Sanders		TIME VISIT/ INSPECTION COMPLETED:	04:45 PM

NARRATIVE

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On 1/22/25, Licensing Program Analyst (LPA) Kevin Mknelly, conducted a case management visit met with Administrator .

On 11/6/24, the department received a Death Notification for R1's passing on 11/4/24 while hospitalized. The notification stated that R1 was sent to the hospital on 11/1/24, approximately 9 AM, for a "declining baseline". R1's death was not expected and R1 was not on hospice care.

On 11/14/24, the Department conducted an initial case management visit regarding the death of R1.

LPA requested and reviewed R1 records prior to the 11/14/24 visit. LPA received additional records on 11/14/24 as well conducting interviews of resident care director, memory care director and three caregivers.

The department also received and reviewed medical records and the death certificate for R1.

At this time, the department finds that resident exhibited changes of condition and had not taken several prescribed medications for three days prior to R1’s 11/1/24 hospitalization. The changes and missed medication were not reported to R1’s physician and assistance was not provided to R1 for medical care.

Maribeth Senty	TELEPHONE: (916) 263-4813
Kevin Mknelly	TELEPHONE: (209) 814-1925
	DATE: 01/22/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/22/2025

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)

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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: MEADOW OAKS OF ROSEVILLE	FACILITY NUMBER: 317005900
	VISIT DATE: 01/22/2025

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32	As a result of this inspection, the following deficiencies were cited on 809-D, per Title 22 Regulations, Division 6. (A)This poses an immediate Health and Safety risk to clients/residents in care. (B) This poses a potential Health and Safety risk, or personal rights violation, to clients/residents in care. Report reviewed. Copy of report and appeal rights provided.

SUPERVISOR'S NAME: Maribeth Senty	TELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Kevin Mknelly	TELEPHONE: (209) 814-1925
LICENSING EVALUATOR SIGNATURE:	DATE: 01/22/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/22/2025

LIC809 (FAS) - (06/04)

Page: 2 of 3

Document Has Been Signed on 01/22/2025 04:41 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: MEADOW OAKS OF ROSEVILLE	FACILITY NUMBER: 317005900
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 01/22/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Section Cited

The licensee shall ensure that residents are regularly observed for changes in physical, mental, emotional and social functioning …When changes such as unusual weight gains or losses or deterioration of mental ability or a physical health condition are observed,
	Deficient Practice Statement
1 2 3 4
	POC Due Date: 01/23/2025
	Plan of Correction
1 2 3 4	Licensee will submit a plan for a review and training of accountable staff for reporting, recording and contacting medical care for changes in conditions- training to be completed within seven days.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

Maribeth Senty	TELEPHONE: (916) 263-4813
Kevin Mknelly	TELEPHONE: (209) 814-1925
	DATE: 01/22/2025

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/22/2025

LIC809 (FAS) - (06/04)

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