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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 317005900
Report Date: 02/15/2021
Date Signed: 02/15/2021 03:15:40 PM



STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office,
, CA
This is an official report of an unannounced visit/investigation of a complaint received in our office on
02/10/2020 and conducted by Evaluator Pheej Cheng
COMPLAINT CONTROL NUMBER: 27-AS-20200210114501
FACILITY NAME:MEADOW OAKS OF ROSEVILLEFACILITY NUMBER:
317005900
ADMINISTRATOR:TANYSHA BORROMEOFACILITY TYPE:
740
ADDRESS:930 OAK RIDGE RDTELEPHONE:
(916) 774-0200
CITY:ROSEVILLESTATE: CAZIP CODE:
95661
CAPACITY:108CENSUS: 69DATE:
02/15/2021
UNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:DEBRA DUVAL; ADMINISTRATORTIME COMPLETED:
03:30 PM
ALLEGATION(S):
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Resident room is malodorous
INVESTIGATION FINDINGS:
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On 2/15/21 at 2 PM, Licensing Program Analyst (LPA) Cheng conducted an unannounced telephone call to facility in regards to allegation above. LPA spoke to current Administrator Debra Duval and explained reason for visit. Telephone visits are conducted in order to be in compliance with the department's procedures regarding COVID-19.

Based on observation, LPA determined that R2's room is malodorous. LPA's visit on 2/13/2020, LPA observed R1's room having a urine smell with soiled clothing on the bathroom floor. S4 was present during LPA's observation of R2's room. S4 stated that there was an initial verbal agreement that R3 would assist in Activities of Daily Living (ADL) except for medication; however, no documentation was presented.

Continuation on LIC 9099C.
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Rayna L BrysonTELEPHONE: (530) 895-5991
LICENSING EVALUATOR NAME: Pheej ChengTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 02/15/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/15/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 3
Control Number 27-AS-20200210114501
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office,
, CA
FACILITY NAME: MEADOW OAKS OF ROSEVILLE
FACILITY NUMBER: 317005900
VISIT DATE: 02/15/2021
NARRATIVE
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LPA informed that there are basic services written in the admissions agreement that has to be provided to the resident along with providing a safe and healthful environment; which was not performed based on observation.

Based on LPA information obtained during investigation, the preponderance of evidence standard has been met; therefore, the above allegation is found to be SUBSTANTIATED. California Code of Regulations (Title 22, Division 6, Chapter 8), are being cited on the attached LIC 9099D.

Exit interview conducted. Two copies of report along were provided and LPA requested for signed copy to be returned.

SUPERVISOR'S NAME: Rayna L BrysonTELEPHONE: (530) 895-5991
LICENSING EVALUATOR NAME: Pheej ChengTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 02/15/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/15/2021
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 27-AS-20200210114501
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office,
, CA

FACILITY NAME: MEADOW OAKS OF ROSEVILLE
FACILITY NUMBER: 317005900
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/15/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
02/25/2021
Section Cited
CCR
87464(f)(1)
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87464 Basic Services (f)(1)Care and supervision as defined in Section 87101(c)(3) and Health and Safety Code section 1569.2(c). This requirement was not met as evidenced by:
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Resident no longer resides at facility. Licensee agreed to conduct an in-service training regarding basic services and submit a self-certification along with training materials and a signed staff roster
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Based on observation, Licensee did not provided house cleaning services for 1 of 1 residents which poses a potential health and safety risk to client in care.
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to LPA by POC date.
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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.
SUPERVISOR'S NAME: Rayna L BrysonTELEPHONE: (530) 895-5991
LICENSING EVALUATOR NAME: Pheej ChengTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 02/15/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/15/2021
LIC9099 (FAS) - (06/04)
Page: 3 of 3