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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 342701201
Report Date: 01/04/2024
Date Signed: 01/04/2024 02:53:27 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH 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
12/11/2023 and conducted by Evaluator Vincent Moleski
PUBLIC
COMPLAINT CONTROL NUMBER: 27-AS-20231211082542
FACILITY NAME:SOARING OAKS CAREHOME RCFEFACILITY NUMBER:
342701201
ADMINISTRATOR:HOUSTON, ANGELINE K.FACILITY TYPE:
740
ADDRESS:9525 SOARING OAKS DRIVETELEPHONE:
(916) 266-3030
CITY:ELK GROVESTATE: CAZIP CODE:
95758
CAPACITY:6CENSUS: 6DATE:
01/04/2024
UNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Olivia AssaTIME COMPLETED:
03:00 PM
ALLEGATION(S):
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Staff are not taking resident to the Doctor
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Vincent Moleski arrived unannounced to deliver findings on this complaint investigation. LPA Moleski spoke with with facility administrator Angeline Houston and explained the purpose of the visit. Houston said staff member Olivia Assa could sign this report in her absence.

This investigation consisted of interviews, observations, and record review. LPA Moleski interviewed Houston, a resident (R1), a resident’s family member (R1 RP), a Veterans Affairs nurse and two facility staff members (S1-S2). LPA Moleski reviewed resident records and facility records.

LPA Moleski reviewed R1’s LIC 602. The LIC 602 was dated 9/28/22. R1 has dementia, according to the LIC 602. The LIC 602 indicated that R1 has a vision impairment, and that R1 wears glasses. Title 22 Section 87705(c)(5) states that “Each resident with dementia shall have an annual medical assessment … and a reappraisal done at least annually.” [continued on 9099-C]
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Vincent Moleski
LICENSING EVALUATOR SIGNATURE:

DATE: 01/04/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/04/2024
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 5
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH 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
12/11/2023 and conducted by Evaluator Vincent Moleski
PUBLIC
COMPLAINT CONTROL NUMBER: 27-AS-20231211082542

FACILITY NAME:SOARING OAKS CAREHOME RCFEFACILITY NUMBER:
342701201
ADMINISTRATOR:HOUSTON, ANGELINE K.FACILITY TYPE:
740
ADDRESS:9525 SOARING OAKS DRIVETELEPHONE:
(916) 266-3030
CITY:ELK GROVESTATE: CAZIP CODE:
95758
CAPACITY:6CENSUS: 6DATE:
01/04/2024
UNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Olivia AssaTIME COMPLETED:
03:00 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Staff are not giving resident their mail
INVESTIGATION FINDINGS:
1
2
3
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5
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9
10
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12
13
Licensing Program Analyst (LPA) Vincent Moleski arrived unannounced to deliver findings on this complaint investigation. LPA Moleski spoke with facility administrator Angeline Houston over the phone and explained the purpose of the visit. Houston said staff member Olivia Assa could sign this report in her absence.

This investigation consisted of interviews, observation, and record review.

LPA Moleski interviewed Houston, a resident (R1), a resident’s family member (R1 RP), and two facility staff members (S1-S2). LPA Moleski reviewed resident records.

During an interview, R1 said R1 receives mail, but not much. R1 said R1 does not receive bank statements every month. With R1’s permission, LPA Moleski reviewed mail left lying on R1’s nightstand. LPA Moleski observed several opened and unopened articles of mail, including an unopened bank statement.
[continued on 9099-C]
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Vincent Moleski
LICENSING EVALUATOR SIGNATURE:

DATE: 01/04/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/04/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 27-AS-20231211082542
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME: SOARING OAKS CAREHOME RCFE
FACILITY NUMBER: 342701201
VISIT DATE: 01/04/2024
NARRATIVE
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LPA Moleski informed R1 of this item. R1 seemed unaware of the statement, and said R1 could not read it due to R1’s vision issues. R1 said R1 has staff read out mail for R1.

During an interview, S1 said R1 receives mail, but not often. S1 said S1 brings in the mail. S1 said S1 reads mail out to R1. S2 said S2 does not bring in the mail when it arrives, but S1 does. S2 said R1 does receive packages occasionally.

The department has determined the following as it relates to the allegation that staff are not giving a resident their mail:

Based on interviews, observation, and record review, the above allegation is UNSUBSTANTIATED, which 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.

No deficiencies were cited regarding the above allegation. An exit interview was held and a copy of this report was left with Assa.
SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Vincent Moleski
LICENSING EVALUATOR SIGNATURE:

DATE: 01/04/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/04/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 5
Control Number 27-AS-20231211082542
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME: SOARING OAKS CAREHOME RCFE
FACILITY NUMBER: 342701201
VISIT DATE: 01/04/2024
NARRATIVE
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R1 did not have an updated LIC 602 as of 12/14/23. LPA Moleski reviewed R1's file on 1/4/24 and observed a new LIC 602 dated 12/18/23.

LPA Moleski reviewed this facility’s plan of operation. Page two of the plan of operation, under a heading entitled "basic services provided," states that the facility shall "plan, arrange and/or provide transportation to medical and dental appointments" and provide "assistance in meeting necessary medical and dental needs." LPA Moleski reviewed this facility's dementia care plan of operation. Page four of this document states that "residents with dementia will have an evaluation and reappraisal of their dementia care needs annually ... or more often as required."

During an interview, R1 said R1 could not see well and R1’s glasses do not help. During an interview, Houston said R1 had glasses, but did not wear them. During an interview, S1 said S1 was aware of R1’s vision issues, and said R1’s vision is sometimes “blurry.” S1 said S1 reads R1’s mail for R1. During an interview, a VA nurse said R1 did not have any upcoming medical appointments. The VA nurse was not aware of any currently ongoing issues regarding R1’s vision.

Title 22 Section 87466 states: "The licensee shall ensure that residents are regularly observed for changes in physical, mental, emotional and social functioning and that appropriate assistance is provided when such observation reveals unmet needs. When changes … are observed, the licensee shall ensure that such changes are documented and brought to the attention of the resident's physician.”

The department has determined the following as it relates to the allegation that staff are not taking a resident to their doctor:

Based on interviews and record review, facility staff did not plan or arrange for medical appointments for R1 as necessary, and therefore, the above allegation is SUBSTANTIATED. A finding that the complaint allegation is substantiated means that the allegation is valid because the preponderance of evidence standard has been met.

This facility is being cited per 22 CCR Sections 87705(c)(5) and 87466. An exit interview was held and a copy of this report was left with Assa.
SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Vincent Moleski
LICENSING EVALUATOR SIGNATURE:

DATE: 01/04/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/04/2024
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 27-AS-20231211082542
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: SOARING OAKS CAREHOME RCFE
FACILITY NUMBER: 342701201
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/04/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
01/11/2024
Section Cited
CCR
87705(c)(5)
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“Each resident with dementia shall have an annual medical assessment … and a reappraisal done at least annually.”

This requirement was not met as evidenced by:
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Licensee has acquired an updated LIC 602 for R1. This plan of correction will be cleared.
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R1's latest LIC 602 was dated 9/28/22. R1 has dementia, according to the LIC 602. Based on record review, R1 did not have a new LIC 602 completed within a year of 9/28/22 as required, which poses a potential health and safety risk.
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Type B
01/11/2024
Section Cited
CCR
87466
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"The licensee shall ensure that residents are regularly observed for changes in physical, mental, emotional and social functioning and that appropriate assistance is provided when such observation reveals unmet needs. When changes … are observed, the licensee shall ensure that such changes are documented and brought to the attention of the resident's physician.”

This requirement was not met as evidenced by:
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Licensee agrees to notify R1's physician of recent vision issues and to plan or arrange for a medical appointment to address those issues.
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R1 wore glasses as of 9/28/22. Facility administrator Angeline Houston was aware that R1 was no longer wearing glasses, and that the prescriptions were not correct. S1 was aware that R1 could not read mail and that R1 had blurry vision. The VA was not made aware of these vision issues and no upcoming appointments were noted as of 12/14/23. Based on interviews and record review, R1's physician was not notified of R1's eye issues, which poses a potential health and safety risk.
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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.
SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Vincent Moleski
LICENSING EVALUATOR SIGNATURE:

DATE: 01/04/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/04/2024
LIC9099 (FAS) - (06/04)
Page: 5 of 5