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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 317005900
Report Date: 03/11/2025
Date Signed: 03/11/2025 04:29:18 PM

Document Has Been Signed on 03/11/2025 04:29 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: 69DATE:
03/11/2025
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:20 PM
MET WITH:Nathan CondieTIME VISIT/
INSPECTION COMPLETED:
04:40 PM
NARRATIVE
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On March 11, 2025, Licensing Program Analyst (LPA) Kevin Mknelly, conducted a case management visit while delivering complaint findings and met with acting Administrator, Nathan Condie .

On March 6, 2025, the department received an incident report from the facility. The report was regarding R1 leaving the memory care enclosed patio by climbing over the fence with the use of patio chair at approximately 7:40 AM on March 6, 2025.
R1 had moved into the facility on March 3, 2025 and was still having difficulty adjusting to this new home.
LPA reviewed facility records and conducted interviews with the Administrator and the med tech who was working on the morning of March 6, 2025. It was found that since admission R1 was not regularly participating in activities and continued to state a desire to leave. On the morning, R1 exited the door by her room to the patio. It was found that the batteries were low on the door alarm and the alarm was low and weak. Caregivers did not hear the alarm when R1 exited. R1 then moved patio furniture to a nearby fence. R1 scaled the fence, fell to the other side and was first responded to by workers on the other side of the fence. Caregivers then responded, R1 received medical assistance for an abrasion.

LPA observed R1 today though R1 declined to be interviewed. Administrator reported that R1 is more emotionally stable and 1:1 observation has been lifted.

Records review found that there were incidents and actions of R1, who has a dementia diagnosis and behavioral expressions of inappropriate behavior, confusion, aggressive behavior, depression and self harm on a physician's assessment dated March 3, 2025.
...report continued
Maribeth SentyTELEPHONE: (916) 263-4813
Kevin MknellyTELEPHONE: (209) 814-1925
DATE: 03/11/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/11/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 3
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: 03/11/2025
NARRATIVE
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Internal staff communication documents reviewed and in places failed to consistently capture and communicate to managers from shift to shift of R1 status.

Though R1 was noted to have increased ambulation instability on 3/4/25 and very confused repeated emergency pull cord use on 3/5/25, R1 continued to be intermittent checks.

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

DATE: 03/11/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/11/2025
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 03/11/2025 04:29 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: 03/11/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
03/25/2025
Section Cited
CCR
87705(c(4)

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Care of Persons with Dementia (c) Licensees who accept and retain residents with dementia shall be responsible for ensuring the following:(4) There is an adequate number of direct care staff to support each resident’s ... safety ...needs as identified in his/her
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LPA observed that the immediate safety issues for R1 have been corrected by R1's wandering behaviors have reduced, door alarms are fully operational after battery replacement, staff pagers and walkie-talkies have been have been upgraded.
Administrator agreed to discuss / review
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current appraisal and demonstrated behaviors This requirement was not met based on records and interviews that found adequate number of staff were not present to implement R1's care need. This posed an immediate risk to R1.
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the possibilities of reducing exit possibilities during times of day. Feasibity and plan to be submitted.
Administrator will review all documents pertaining to this incident and submit updated written communication forms. POC due 3/25/25

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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: 03/11/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/11/2025

LIC809 (FAS) - (06/04)
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