317005900-2-1-2021-27-AS-KHOS-BXWKBV-20210204064608

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 317005900
Report Date: 02/01/2021
Date Signed: 02/01/2021 02:46:58 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

This is an official report of an unannounced visit/investigation of a complaint received in our office on
07/16/2020 and conducted by Evaluator Sarena Keosavang

PUBLIC

COMPLAINT CONTROL NUMBER: 27-AS-20200716144735

FACILITY NAME:	MEADOW OAKS OF ROSEVILLE		FACILITY NUMBER:	317005900
ADMINISTRATOR:	JASMINE RIDENOUR		FACILITY TYPE:	740
ADDRESS:	930 OAK RIDGE RD		TELEPHONE:	(916) 774-0200
CITY:	ROSEVILLE	STATE: CA	ZIP CODE:	95661
CAPACITY:	108	CENSUS: 64	DATE:	02/01/2021
		UNANNOUNCED	TIME BEGAN:	02:00 PM
MET WITH:	Laura Benson		TIME COMPLETED:	02:50 PM

ALLEGATION(S):

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Personal Rights.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Sarena Keosavang contacted the facility via telephone due to COVID-19 and pre-cautionary measures on 2/1/2021 to deliver complaint finding for a complaint Community Care Licensing (CCL) received on 7/16/2020. LPA spoke with Interim Executive Director (IED), Laura Benson, and explained the purpose of the telephone call.

Throughout the course of the complaint investigation the Department conducted interviews and obtained pertinent documents relevant to the allegation: personal rights. According to Complainant, S1 was instructed to work the entire shift despite expressing concerns of being COVID-19 positive. Staff (S1) reported to Executive Director (ED) Jasmine Ridenour and Assistant Executive Director (AED) Samantha Murphy was experiencing COVID-19 symptoms such as fever, nausea, diarrhea, and sore throat. S1 notifed management of being exposed to an individual who is COVID-19 positive. S1 was concern about spreading the virus to other staff members and residents.

************ Continue on LIC 809-C *************

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Anthony Perez	TELEPHONE: (916) 263-4700
LICENSING EVALUATOR NAME: Sarena Keosavang	TELEPHONE: (209) 202-9552
LICENSING EVALUATOR SIGNATURE:	DATE: 02/01/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/01/2021

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

LIC9099 (FAS) - (06/04)

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Control Number 27-AS-20200716144735

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

FACILITY NAME: MEADOW OAKS OF ROSEVILLE	FACILITY NUMBER: 317005900
	VISIT DATE: 02/01/2021

NARRATIVE

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Interviews with ED indicated that S1 called the community on 7/3/2020 and reported that S1 may have been exposed to a COVID-19 positive individual. ED stated S1 did not report that S1 was experiencing any COVID-19 symptoms. ED stated she reached out to Nurse Consultant, Josh Allen, right away to ask for recommendation and guidance. Nurse consultant advised that staff’s exposure to COVID-19 was a third hand exposure and suggest for staff to continue to work S1’s shift at the community on 7/3/2020 and 7/4/2020. Assuming staff is asymptomatic. On 7/3/2020, S1 was tested and result came back positive. The facility notified S1 right away and did not schedule S1 to return to work for several days.

Due to the information CCL finds the allegation to be UNSUBSTANTIATED- A finding that a complaint allegation is unsubstantiated means that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred.

An exit interview was conducted.

A copy of this report will be provided electronically to Interim Executive Director, Laura Benson, via email. IED to return a signed copy to CCL, a signed copy should be retained for facility records.

SUPERVISOR'S NAME: Anthony Perez	TELEPHONE: (916) 263-4700
LICENSING EVALUATOR NAME: Sarena Keosavang	TELEPHONE: (209) 202-9552
LICENSING EVALUATOR SIGNATURE:	DATE: 02/01/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/01/2021

LIC9099 (FAS) - (06/04)

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