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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 342701211
Report Date: 03/12/2024
Date Signed: 03/12/2024 04:16:48 PM

Unsubstantiated


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
01/11/2024 and conducted by Evaluator Pang Lee
PUBLIC
COMPLAINT CONTROL NUMBER: 27-AS-20240111152353
FACILITY NAME:STEWART OAKS VILLAFACILITY NUMBER:
342701211
ADMINISTRATOR:FERREIRA, MELANIEFACILITY TYPE:
740
ADDRESS:1099 STEWART ROADTELEPHONE:
(916) 222-1010
CITY:SACRAMENTOSTATE: CAZIP CODE:
95864
CAPACITY:6CENSUS: 5DATE:
03/12/2024
UNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Melanie FerreiraTIME COMPLETED:
04:30 PM
ALLEGATION(S):
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Staff did not report incident to appropriate parties
Staff did not assist resident with incontinence care
Staff did not assist resident with showering
Staff do not ensure that resident's dietary needs are met
INVESTIGATION FINDINGS:
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On 03/12/2024 at 2:00 PM, Licensing Program Analyst (LPA) Pang Lee arrived unannounced to this facility to conduct a complaint visit. LPA met with administrator Melanie Ferreira and explained the purpose of the visit. The purpose of this visit is to deliver complaint findings for the allegations above. The current census is 5 with 2 facility staff presents. An interview with conducted with administrator Melanie Ferreira and Licensee Kanwal Randhaua.

Allegation: Staff did not report incident to appropriate parties
It was alleged that staff did not report the incident to appropriate parties. This investigation consisted of records reviewed, interviews with staff, residents, and the resident responsible party. LPA Lee interviewed 5 out of 5 residents who have not witnessed resident 1 (R1) having a fall on 12/30/2023. LPA Lee also interviewed 5 facility staff who have not witnessed (R1) having a fall on 12/30/2023.

Continued LIC 9099-C
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Czarrina A Camilon-Lee
LICENSING EVALUATOR NAME: Pang Lee
LICENSING EVALUATOR SIGNATURE:

DATE: 03/12/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/12/2024
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 6
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
01/11/2024 and conducted by Evaluator Pang Lee
PUBLIC
COMPLAINT CONTROL NUMBER: 27-AS-20240111152353

FACILITY NAME:STEWART OAKS VILLAFACILITY NUMBER:
342701211
ADMINISTRATOR:FERREIRA, MELANIEFACILITY TYPE:
740
ADDRESS:1099 STEWART ROADTELEPHONE:
(916) 222-1010
CITY:SACRAMENTOSTATE: CAZIP CODE:
95864
CAPACITY:6CENSUS: 5DATE:
03/12/2024
UNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Melanie FerreiraTIME COMPLETED:
04:30 PM
ALLEGATION(S):
1
2
3
4
5
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8
9
Licensee does not provide required staff training
INVESTIGATION FINDINGS:
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On 03/12/2024 at 2:00 PM, Licensing Program Analyst (LPA) Pang Lee arrived unannounced to this facility to conduct a complaint visit. LPA met with administrator Melanie Ferreira and explained the purpose of the visit. The purpose of this visit is to deliver complaint findings for the allegations above. The current census is 5 with 2 facility staff presents. An interview with conducted with administrator Melanie Ferreira and Licensee Kanwal Randhaua.

Allegation: Licensee does not provide required staff training
It was alleged that Licensee does not provide required staff training. This investigation consisted of records reviewed and interviews with facility staff. LPA Lee interviewed 5 facility staff who denies that the licensee does not provide required training to staff. It was learned through interviews that new facility staff receives 20 hours through shadowing and 20 hours from training from administrator through YouTube videos. Based on records view 1 out of 7 facility staff did not consent that 40 hour of training was completed.
Continued LIC 9099-C
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Czarrina A Camilon-Lee
LICENSING EVALUATOR NAME: Pang Lee
LICENSING EVALUATOR SIGNATURE:

DATE: 03/12/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/12/2024
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 6
Control Number 27-AS-20240111152353
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: STEWART OAKS VILLA
FACILITY NUMBER: 342701211
VISIT DATE: 03/12/2024
NARRATIVE
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 Staff 1 (S1) records reveal that (S1) refused to sign that (S1) received 40 hours of training and was providing care to residents in care; therefore, it is unclear if (S1) received the required training. As a result, this allegation is SUBSTANTIATED. A finding that the complaint is substantiated means that the allegations are valid because the preponderance of the standard has been met. Deficiencies cited on the LIC 9099-D, per Title 22 Regulations. An exit interview was conducted with and a copy of this LIC 9099, LIC 9099-D page and appeal rights provided to facility.
SUPERVISORS NAME: Czarrina A Camilon-Lee
LICENSING EVALUATOR NAME: Pang Lee
LICENSING EVALUATOR SIGNATURE:

DATE: 03/12/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/12/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 6
Control Number 27-AS-20240111152353
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: STEWART OAKS VILLA
FACILITY NUMBER: 342701211
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/12/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
03/22/2024
Section Cited
CCR
87411(c)
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87411 Personnel Requirements – General
(c) All RCFE staff who assist residents with personal activities of daily living shall receive initial and annual training as specified in Health and Safety Code sections 1569.625 and 1569.69. This requirement was not met as evidence by:
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Administrator stated she will review section 87411(c) and send LPA Lee a statement showing acknowledgement and understanding of the regulation cited.
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Based on record review, the administrator did not comply with the section cited above when a employee did not sign off receiving initial and annual training; this posed/poses a potential health, safety, or personal rights risk to persons in care.

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Administrator agrees to ensure all staff are trained prior to providing care and supervision to residents in care. POC due by 03/22/2024 by 5 PM.
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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: Czarrina A Camilon-Lee
LICENSING EVALUATOR NAME: Pang Lee
LICENSING EVALUATOR SIGNATURE:

DATE: 03/12/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/12/2024
LIC9099 (FAS) - (06/04)
Page: 4 of 6
Control Number 27-AS-20240111152353
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: STEWART OAKS VILLA
FACILITY NUMBER: 342701211
VISIT DATE: 03/12/2024
NARRATIVE
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 LPA Lee also spoke to (R1) responsible party who stated there was no concerns with facility staff not reporting (R1) incident report and only recall (R1) having a fall in September and that responsible party was informed. LPA Lee also checked the department’s Electronic Facility Files, and no fall incident was reported to the department. Moreover, a Hospice Home Health aide and LVN Nurse has stated they have not witnessed a resident having a fall during their visits. The investigation revealed the preponderance of evidence standards have not been met; therefore, the above allegations are found to be UNSUBSTANTIATED. A finding that the complaint allegations are UNSUBSTANTIATED means that although the allegations may have happened or are valid, there is not a preponderance of the evidence to prove that the alleged violation(s)occurred.

Allegation: Staff did not assist resident with showering

It was alleged that staff did not assist residents with showering. This investigation consisted of records reviewed, interviews with staff, residents, and the resident responsible parties. LPA Lee interviewed 5 out of 5 residents who have no concerns with facility staff not assisting residents with showering. LPA Lee also interviewed 5 facility staff who denied the allegation. LPA Lee interviewed (R1)’s responsible party who has no concern with staff not assisting (R1) with showering. It was learned that (R1) gets a shower by (R1) hospice nurse once a week. Records review also revealed that in the month of November (R1) received 4 showers by hospice nurse and 6 sponge baths by facility staff and for the for the month of December (R1) received 5 showers by hospice nurse and 7 sponge baths by facility staff. For the month of January (R1) receives 4 showers by hospice nurse and 6 sponge baths by facility staff. Moreover, LPA Lee interviewed (R1) hospice nurse who has no concerns with (R1) not showers from facility staff; therefore, the above allegations are found to be UNSUBSTANTIATED. A finding that the complaint allegations are UNSUBSTANTIATED means that although the allegations may have happened or are valid, there is not a preponderance of the evidence to prove that the alleged violation(s)occurred.


Allegation: Staff did not assist resident with incontinence care

It was alleged that Staff did not assist resident with incontinence care. This investigation consisted of records reviewed, interviews with staff, residents, and the resident responsible parties. LPA Lee interviewed 5 out of 5 residents who have no concerns with facility staff not assisting residents with incontinence care. LPA Lee also interviewed 5 facility staff who denied the allegation.

Continued LIC 9099-C

SUPERVISORS NAME: Czarrina A Camilon-Lee
LICENSING EVALUATOR NAME: Pang Lee
LICENSING EVALUATOR SIGNATURE:

DATE: 03/12/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/12/2024
LIC9099 (FAS) - (06/04)
Page: 5 of 6
Control Number 27-AS-20240111152353
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: STEWART OAKS VILLA
FACILITY NUMBER: 342701211
VISIT DATE: 03/12/2024
NARRATIVE
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LPA Lee interviewed (R1)’s responsible party who has no concern with staff not assisting (R1) with incontinence care. LPA Lee interviewed (R1) hospice nurse who has no concerns with (R1) not getting (R1) incontinence care needs from facility staff. (R1) Care Notes revealed that (R1) is getting assistance with prompting to use the bathroom along with getting brief changed throughout the day; therefore, the above allegations are found to be UNSUBSTANTIATED. A finding that the complaint allegations are UNSUBSTANTIATED means that although the allegations may have happened or are valid, there is not a preponderance of the evidence to prove that the alleged violation(s)occurred.

Allegation: Staff do not ensure that resident's dietary needs are met

It was alleged that staff do not ensure that residents’ dietary needs are met. This investigation consisted of records reviewed, interviews with staff, residents, and the resident responsible parties. LPA Lee interviewed 5 out of 5 residents who have no concerns with facility staff not ensuring that residents dietary needs are met. LPA Lee also interviewed 5 facility staff who denied the allegation. LPA Lee interviewed (R1)’s responsible party who has no concern with the food being served to (R1). LPA Lee also interviewed (R2) responsible party who also shares no concerns with the food being served to (R2). During 01/16/2024 LPA Lee observed for breakfast residents were served scrabble eggs, sausage, bacon, and biscuit. For lunch LPA Lee observed residents being served fish sticks, fries, salad, and green beans. For dinner LPA Lee observed residents being served pork chop, mash potatoes, salad, green beans, and apples. During today’s visit 03/12/2024, LPA Lee observed fruits and vegetables being served to residents during breakfast and lunch. Therefore, the above allegations are found to be UNSUBSTANTIATED. A finding that the complaint allegations are UNSUBSTANTIATED means that although the allegations may have happened or are valid, there is not a preponderance of the evidence to prove that the alleged violation(s)occurred. Per California Code of Regulations, Title 22, no deficiencies were observed during this visit.

An exit interview was conducted, and a copy of this report was

SUPERVISORS NAME: Czarrina A Camilon-Lee
LICENSING EVALUATOR NAME: Pang Lee
LICENSING EVALUATOR SIGNATURE:

DATE: 03/12/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/12/2024
LIC9099 (FAS) - (06/04)
Page: 6 of 6