342700805-1-26-2026-59-AS-MSEY-DQZQ3Q-20260205104905

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 342700805
Report Date: 01/22/2026
Date Signed: 01/26/2026 09:53:37 AM

Substantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

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

This is an official report of an unannounced visit/investigation of a complaint received in our office on
11/19/2025 and conducted by Evaluator Kevin Mknelly

PUBLIC

COMPLAINT CONTROL NUMBER: 59-AS-20251119202205

FACILITY NAME:	NORTHERNCARE FACILITY		FACILITY NUMBER:	342700805
ADMINISTRATOR:	WOODWARD, ROSE BALURO		FACILITY TYPE:	740
ADDRESS:	5016 WATERBURY WAY		TELEPHONE:	(530) 762-8199
CITY:	FAIR OAKS	STATE: CA	ZIP CODE:	95628
CAPACITY:	6	CENSUS: 5	DATE:	01/22/2026
		UNANNOUNCED	TIME BEGAN:	01:30 PM
MET WITH:	Rose Woodward		TIME COMPLETED:	02:15 PM

ALLEGATION(S):

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Facility staff are not following infection control procedures.

Staff does not follow doctor's orders for resident.

INVESTIGATION FINDINGS:

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On 1/22/26, Licensing Program Analyst (LPA) Kevin Mknelly spoke to administrator, to deliver complaint findings for the above allegation.

LPA reviewed resident records, facility records and conducted extensive interviews.
LPA finds that the allegations cited above are substantiated.

Interviews found that R1 has been diagnosed with an infectious illness which the Administrator was aware of and treatment has been prescribed. On 12/11/25, LPA Mknelly observed care of R1, R1’s room, staff handling of R1’s laundry and interviewed Administrator. Observations and interviews found staff not washing hands before and after use of gloves, staff not changing gloves between tasks, staff touching surfaces with potentially infectious gloves, and Administrator stated their dryer does not get hot enough to dry clothing unless run twice per load. On 1/6/26, in interview, Admin stated that they do not have a written physician’s order for R1’s skin treatment, staff have at times left the treatment on in excess of the

Substantiated

Estimated Days of Completion:

SUPERVISORS NAME: Maribeth Senty
LICENSING EVALUATOR NAME: Kevin Mknelly
LICENSING EVALUATOR SIGNATURE:	DATE: 01/22/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/22/2026

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 59-AS-20251119202205

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

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

FACILITY NAME: NORTHERNCARE FACILITY	FACILITY NUMBER: 342700805
	VISIT DATE: 01/22/2026

NARRATIVE

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time prescribed on the medication label and has used doses of the medication that was prescribed to a family member. R1’s skin treatment medication was also not recorded as centrally stored.

As a result of this investigation, LPA finds allegation to be (S) Substantiated - A finding that the complaint is Substantiated means that the allegation is valid because the preponderance of the evidence standard has been met. 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.

Report reviewed with Administrator . Copy of this report and appeal rights provided.

SUPERVISORS NAME: Maribeth Senty
LICENSING EVALUATOR NAME: Kevin Mknelly
LICENSING EVALUATOR SIGNATURE:	DATE: 01/22/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/22/2026

LIC9099 (FAS) - (06/04)

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Control Number 59-AS-20251119202205

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

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

FACILITY NAME: NORTHERNCARE FACILITY	FACILITY NUMBER: 342700805
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 01/22/2026

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 02/23/2026 Section Cited CCR 87465(e)	1 2 3 4 5 6 7	Incidental Medical and Dental Care (e) For every prescription and nonprescription PRN medication for which the licensee provides assistance there shall be a signed, dated written order from a physician, on a prescription blank, maintained in the residents file, and a label on the medication.	1 2 3 4 5 6 7	Licensee will submit proof of registration for training provided by a ccld vendorized medication specific for RCFEs training by the POC date od 1/23/26. The training is to be completed by 2/23/26 and proof will be submitted.
	8 9 10 11 12 13 14	This requirement was not met based on records and statements that found R1's medications were not administered as ordered. This posed an immediate risk to resident.	8 9 10 11 12 13 14
Type B 02/23/2026 Section Cited CCR 87470(a)(4)(C)	1 2 3 4 5 6 7	Infection Control Requirements (a)(4)(C) Gloves shall be removed and discarded in the nearest appropriate waste receptacle with a tight-fitting cover immediately following the glove use as required. This requirement was not met based on	1 2 3 4 5 6 7	Licensee will submit proof of registration for training provided by a ccld vendorized medication specific infection control training for all staff.. The training is to be completed by 2/23/26 and proof will be submitted.
	8 9 10 11 12 13 14	observations and interviews. This posed an potential risk to residents health and safety.	8 9 10 11 12 13 14

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

SUPERVISORS NAME: Maribeth Senty
LICENSING EVALUATOR NAME: Kevin Mknelly
LICENSING EVALUATOR SIGNATURE:	DATE: 01/22/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/22/2026

LIC9099 (FAS) - (06/04)

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