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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 317005900
Report Date: 01/14/2025
Date Signed: 02/13/2025 02:32:06 PM

Document Has Been Signed on 02/13/2025 02:32 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 ROSEVILLEFACILITY NUMBER:
317005900
ADMINISTRATOR/
DIRECTOR:		JESSICA SANDERSFACILITY TYPE:
740
ADDRESS:930 OAK RIDGE RDTELEPHONE:
(916) 774-0200
CITY:ROSEVILLESTATE: CAZIP CODE:
95661
CAPACITY: 108TOTAL ENROLLED CHILDREN: 0CENSUS: 70DATE:
01/14/2025
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:50 AM
MET WITH:Jessica SandersTIME VISIT/
INSPECTION COMPLETED:
12:45 PM
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**Report amended- a deficiency was removed due to incorrect CCR. Deficiency re-issued 2/13/25.**
On 1/14/25, Licensing Program Analyst (LPA) Kevin Mknelly, arrived to deliver incident investigation findings and met with Executive Director.

On 5/3/24, while LPA was present to investigate facility reported elopement by R1, on 4/20/24, LPA was notified of R1’s unexpected death on 5/2/24. LPA returned on 5/16/24 to conduct further investigation. LPA requested records related to R1 and conducted staff interviews.
Records review for R1 found that R1 sustained a Subdural Hematoma on 1/1/24 following an unwitnessed fall at the facility. Following hospitalization for the injury, Hospice care was initiated on 1/7/24. R1 was also diagnosed to have dementia and documented as a fall risk. Hospice records included recommendation that R1 has standby assist while ambulating.
Hospice records stated that on 5/1/24, R1 had a unwitnessed fall from R1’s bed to a fall mat. No injury, pain or agitation was observed at the time of the fall. Medication Technician (Med Tech) S1 reported to Hospice that the fall occurred approximately 1 hour after morning medications. Based on R1’s medication list, the medications R1 was administered included 0.5 mg of Lorazepam (Ativan) , Metroprlol 10 mg, Quetiapine (Seroquel) 50 mg. The administered medications given list possible side effects of drowsiness, dizziness or unsteadiness.
On 5/1/24, S1 reported to the Hospice nurse that since R1’s increased current doses of Lorazepam and Quetiapine on 4/26/24, R1 was observed to be sleeping approximately 15 hours per day. Per Hospice records, the reason for Lorezepam listed was for R1’s anxiety and Quetiapine for agitation, restlessness and exit seeking.
Maribeth SentyTELEPHONE: (916) 263-4813
Kevin MknellyTELEPHONE: (209) 814-1925
DATE: 01/14/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/14/2025
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: 01/14/2025
NARRATIVE
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Records and statements found that on 5/2/24, at approximately 12:00 PM, R1 exited the residence to an enclosed courtyard. Staff, S2, heard the door alarm and went to that exit. S2 was assigned other residents to care for but had witnessed R1 to be very active the morning. S2 observed R1 to be lying in the bark on their left side with R1's right cheek on the ground. S2 stated that R1's wig had fallen off and was on the ground nearby. S2 encouraged R1 to remain where R1 was until med tech (S1) arrived to assess. R1 reported a sore ankle to S2. When S3 and S4 arrived to assist, S2 returned to attend to other residents.

On 5/16/24, LPA inspected the area R1 was observed to have fallen on 5/2/24. R1 had fallen to the left after exiting to the courtyard. LPA observed that where R1 had fallen into the landscaping wood chips, the wood chips were approximately 3 inches lower that the surface of the sidewalk.

S3 was assigned to R1 the morning of 5/2/24. In interview with LPA, S3 described that R1 “had kept me on my toes” the morning of 5/2/24. S3 stated that on 05/02/24, R1 observed to be occasionally off balance as they R1 moved around the community but had no observed falls. S3 was the second staff to arrive after the door exit alarm sounded.

S4 stated that when they arrived to the courtyard, R1 was seated in the wood chips with their back against the wall of the building. S4 reported that they asked R1 if R1 had hit their head and R1 responded yes. Med tech, S1, arrived to assess R1 and determined it was safe to move R1 inside. S3 and S4 provided physical assist escort to R1 as they appeared “unsteady”. R1 was then sat in the common area.

Med tech, S1, reported in an interview with LPA that S1 spoke with R1 and did a body check of legs, arms and head. R1 did not report pain and there were no apparent scrapes, bumps or bruises at the time of S1’s assessment.


S1 notified Hospice of the fall and report of R1 hitting their head. A Hospice nurse was to be sent to assess R1 and arrived at the facility at approximately 3:00PM. (Note: Medication records and statements received by LPA, indicate R1 received sedating medications between the fall and Hospice’s arrival.)
Report continued...
SUPERVISOR'S NAME: Maribeth SentyTELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Kevin MknellyTELEPHONE: (209) 814-1925
LICENSING EVALUATOR SIGNATURE:

DATE: 01/14/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/14/2025
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: 01/14/2025
NARRATIVE
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S1 was told, by Hospice, to give Acetaminophen (Tylenol) if pain was present. S1 stated that they administered Tylenol to R1, however, LPA checked PRN records and saw no recorded Tylenol dispensed on 5/2/24.

S1 stated that S3 and S4 assisted R1 to stand and walk into the common area, past the dining area and then to the couch by the fireplace.

S1 stated they though a Hospice aide came shortly after R1’s fall to provide R1 a bath and that there were no reported concern from the aide. S1 did not speak further with hospice before the end of the shift at 2 PM. S1 notified the PM med tech, S5, of the incident and hospice contact.
S1 indicated they last saw R1 post bath, sitting on a chair in their room, before S1 left their shift.

Hospice Nurse notes for 5/2/24 fall assessment stated: “PATIENT LYING IN THEIR HOSPITAL BED AND AROUSABLE TO VERBAL AND TACTILE STIMULATION. UPON ASSESSMENT, PATIENT VERBALIZED THAT THEIR HEAD HURTS AND FACILITY MEDTECH INSTRUCTED TO ADMINISTER ACETAMINOPHEN FOR PAIN MANAGEMENT. PATIENT ABLE TO MOVE UPPER AND LOWER EXTREMITIES WITHOUT ANY NEW LIMITATION TO RANGE OF MOTION. NO REDNESS NOTED ON THEIR SKIN, NEW BRUISE NOTED TO THEIR RIGHT BUTTOCKS, AND NO SKIN TEAR OBSERVED. LEFT ANKLE IS SLIGHTLY SWOLLEN WITH NO SIGNS OF NONVERBAL PAIN NOTED DURING PALPATION. NO SIGNS OF ANY BUMP ON THE HEAD OBSERVED AS PATIENT MIGHT HAVE HIT THEIR HEAD PER FACILITY.”

PM shift med tech S5 reported to LPA that facility medication records did not show only that R1 received their regularly scheduled medications at 2:00 PM. (Note in medication Administration record (MAR for 5/2/24, 2 PM- “H” is documented.) S5 recalls a conversation with a male hospice nurse who had arrived to assesses R1. At approximately 3:00 PM. S5 was told by the hospice nurse, that R1 had a left ankle injury and a right sided "butt bruise". S5 observed R1 to hold their head and squint during the assessment by the Hospice nurse. S5 reminded the Hospice nurse that R1 had had a previous brain bleed at the beginning of the year.
Report continued...
SUPERVISOR'S NAME: Maribeth SentyTELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Kevin MknellyTELEPHONE: (209) 814-1925
LICENSING EVALUATOR SIGNATURE:

DATE: 01/14/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/14/2025
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: 01/14/2025
NARRATIVE
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On 5/2/24, PM caregiver S6 stated in interview with LPA that as S6 was starting their shift, a male Hospice nurse was leaving. R1 was observed to be asleep and in bed. Staff were to check on R1 every 30-40 minutes. S6 understood that Hospice had given R1 "something for agitation". (LPA did not see record of an as needed medication having been given to R1 during their visit on 5/2/24).

S6 indicated that they observed when R1 was administered Ativan, R1 may be sleepy for some time.
When S6 checked on R1 at around 3:30, R1 had moved from R1's bed and appeared to be resting in a chair in R1's room.

S6 checked on R1 again at around 4 PM. S6 found R1 to be slouched on the floor with their arm and head on the side of the bed. R1 appeared to be tremoring and struggling to breath. There was vomit and bowel incontinence on the bed and floor by R1. S6 repositioned R1 to try to provide and open airway.

Med tech, S5, was called. Hospice was called by med tech, S5. A female nurse and the male nurse from earlier arrived.
LPA asked what the procedure is for an unwitnessed fall and resident hitting their head. S6 said their understanding is that Hospice is to be called if the resident appears “okay”.

LPA interviewed Executive Director (ED), Jessica Sanders and asked what the policy is for unwitnessed falls for residents known or suspected to have hit their head in the fall. ED responded that the resident who fell should not be moved and if it is suspected the resident hit their head, 9-1-1 should be called and then hospice notified.

Placer County death certificate for R1 identified immediate cause of death as Senile Dementia with other significant conditions of Hypertension and Recurrent falls.

Report continued...
SUPERVISOR'S NAME: Maribeth SentyTELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Kevin MknellyTELEPHONE: (209) 814-1925
LICENSING EVALUATOR SIGNATURE:

DATE: 01/14/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/14/2025
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: 01/14/2025
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Based on the evidence found in this investigation, the department finds that the staff did not ensure sufficient care and supervision was provided to resident (R1) and staff did not seek medical treatment in a timely manner for resident in care. R1 was known to need assistance with ambulation due to a history of falls, behavioral expressions and effects of medications. Furthermore, staff interviewed were found to be unclear of facility policy mandating call to 9-1-1 for unwitnessed falls with report of a resident hitting their head or when to call Hospice only. Executive Director and Generations Director was present at the facility yet were not informed or aware of the incident at the time on 5/2/24.

It was additionally found during hospice records review that R1 had successfully left the building on 4/5/24 and was found in the facility’s parking lot. There is no record of this incident having been reported to CCLD. R1 had a successful elopement on 4/20/24 for which the facility was cited by CCLD. On 4/26/24, R1 had an attempted elopement where it was noted that R1 was able to get out of the facility and on to the facility grounds before staff responded and R1 returned to memory care. The 4/26/24 incident of R1’s elopement was also not reported to CCLD.

Lastly, in this investigation, it was found that Administrator failed to ensure staff resources were available for identified needs of R1, staff were not properly trained for unwitnessed falls procedures, failed to report incidents failed to ensure walkways accessible to R1 were safe given R1’s ambulation deficits.


The following deficiencies were cited on 9099-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.

An immediate civil penalty in the amount of $500.00 is to be assessed for a resident sustaining a serious bodily injury while in care at this facility. As a result of resident’s injury, the violation warrants a civil penalty assessment based on health and safety code 1569.49. At this time, the civil penalty assessment is under review. LPA will return at a future date to assess a civil penalty if warranted.

Report reviewed. Copy of report and appeal rights provided.

SUPERVISOR'S NAME: Maribeth SentyTELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Kevin MknellyTELEPHONE: (209) 814-1925
LICENSING EVALUATOR SIGNATURE:

DATE: 01/14/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/14/2025
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 02/13/2025 02:32 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: 01/14/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Request Denied
Type A
01/15/2025
Section Cited
CCR
87468.2(a)(4)

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Additional Personal Rights of Residents in Privately Operated Facilities
(a) In addition to the rights listed in Section 87468.1, ...elderly shall have all of the following personal rights:
(4) To care, supervision, and services that meet their individual needs and are
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Licensee agreed to submit a plan for assessing staffing and staff communication for residents known to have exit seeking behavior.
This POC is due 1/14/25.
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delivered by staff that are sufficient in numbers, qualifications, and competency to meet their needs.
This requirement was not met as evidenced by statements and records showing lack of supervision at the time of R1’s fall on 5/2/24. This posed an immediate risk to R1.
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Immediate civil penalty assesses

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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 SentyTELEPHONE: (916) 263-4813
Kevin MknellyTELEPHONE: (209) 814-1925

DATE: 01/14/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/14/2025

LIC809 (FAS) - (06/04)
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Document Has Been Signed on 01/14/2025 12:32 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: 01/14/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
01/15/2025
Section Cited
CCR
87405(h)(5)

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Administrator - Qualifications and Duties(h) (5) Provide or ensure the provision of services to the residents with appropriate regard for the residents' physical and mental well-being and needs, including those services identified… This requirement was not met based on interviews and records that
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Licensee agrees to submit a plan for review and communication of any incidents or concerns for resident safety issues to be brought to the ED or designee attention in a timely manor.
POC by 1/15/24.
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found R1's supervision regularly did not receive the services of ambulation supervision, staff were unaware of when 9-1-1 was to be called and Admin was unaware of a significant event in the facility. This posed an immediate risk to the resident
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Deficiency Dismissed
Type B
01/28/2025
Section Cited
CCR87211(a)(1)

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87211 Reporting Requirements(a)(1) A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence of any of the events specified (D) Any incident which threatens the welfare, safety or health of
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Licensee agrees to submit the procedure of incident, to begin report, to review to submitting to CCLD for all reportable incidents by the POC date of 1/28/25.
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any resident… This requirement was not met based on interviews and records which found unreported incidents of elopements by R1. This posed a potential risk to resident.
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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 SentyTELEPHONE: (916) 263-4813
Kevin MknellyTELEPHONE: (209) 814-1925

DATE: 01/14/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/14/2025

LIC809 (FAS) - (06/04)
Page: 7 of 8


Document Has Been Signed on 01/14/2025 12:32 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: 01/14/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Request Denied
Type B
01/28/2025
Section Cited
CCR
87303(a)

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87303 Maintenance and Operation (a) The facility shall be … safe, … and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents. This requirement was not met based on
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Licensee agreed to to submit the procedure for safety checks of the community grounds to include check lists utilized and persons respibsible for the reviews and corrective actions by the POC 1/28/25.
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observations which found surface from walkway to landscaping presented an uneven surface for un unsteady, unsupervised resident to fall. This poses a potential risk to residents.
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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 SentyTELEPHONE: (916) 263-4813
Kevin MknellyTELEPHONE: (209) 814-1925

DATE: 01/14/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/14/2025

LIC809 (FAS) - (06/04)
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