345920108-7-22-2025-59-AS-MSEY-DJUNR7-20250723104105

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 345920108
Report Date: 07/22/2025
Date Signed: 07/22/2025 01:02:49 PM

Unfounded

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
05/13/2025 and conducted by Evaluator Sabrina Calzada

PUBLIC

COMPLAINT CONTROL NUMBER: 59-AS-20250513170952

FACILITY NAME:	OAKWOOD MEADOWS ASSISTED LIVING		FACILITY NUMBER:	345920108
ADMINISTRATOR:	TORGERSEN, DANIEL		FACILITY TYPE:	740
ADDRESS:	7241 CANELO HILLS DR		TELEPHONE:	(916) 722-2800
CITY:	CITUS HEIGHTS	STATE: CA	ZIP CODE:	95610
CAPACITY:	78	CENSUS: 73	DATE:	07/22/2025
		UNANNOUNCED	TIME BEGAN:	10:30 AM
MET WITH:	Karen Padilla, Director of Nursing		TIME COMPLETED:	01:00 PM

ALLEGATION(S):

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Staff mismanaged resident's medications.
Staff did not seek medical attention for the resident in a timely manner.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Sabrina Calzada arrived unannounced to complete the investigation and deliver complaint findings. LPA met with Karen Padilla, Director of Nursing (DON), and Kayla Peria, Director of Care and Admissions, and stated the reason for the inspection.

During the investigation, LPA interviewed the Administrator, DON, Director of Care and Admissions and a family member of resident (R1), who is the subject of the investigation. LPA reviewed pertinent documentation relating to (R1), including but not limited to: the physician's report, pre-placement appraisal, appraisal, the Medication Administration Record (MAR), and charting notes.

(R1) moved to the community in October 2024 with a diagnosis of CVA (stroke), vision impairment, Diabetes Mellitus 2, and requiring assistance with feeding, dressing, showers and incontinence care. Resident previously had a kidney transplant, was fully aware, conscious and coherent and able to follow instructions. Resident was sent to the hospital on May 8, 2025 for not feeling well and was later transferred to a skilled nursing facility. The results of the investigation are as follows: cont on 9099C-1..

Unfounded

Estimated Days of Completion:

SUPERVISORS NAME: Maribeth Senty
LICENSING EVALUATOR NAME: Sabrina Calzada
LICENSING EVALUATOR SIGNATURE:	DATE: 07/22/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/22/2025

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 59-AS-20250513170952

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: OAKWOOD MEADOWS ASSISTED LIVING	FACILITY NUMBER: 345920108
	VISIT DATE: 07/22/2025

NARRATIVE

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9099C-1.. Allegation: Staff mismanaged resident's medications. The allegation states that staff has forgotten to give (R1) medications before, and don't check (R1's) blood pressure or blood sugars.

The MAR was reviewed for months April and May 2025. The April MAR notes that (R1) was out of the facility from April 4 through April 26, and all medications were administered as prescribed from April 1 through April 4, and resumed on April 26. The MAR also notes that (R1) refused the medication,Brimonidine- eye drops, on April 27, 2025 (5:43 pm). Additionally, the MAR reflects that several new medications were prescribed to start on April 26 when (R1) returned to the community, and that they were administered as ordered. Facility charting notes document that (R1) was sent to the hospital on April 4, due to having blood in the urinal, and that (R1) was later transferred to a skilled nursing on April 21. The May MAR notes that (R1) was administered medications, as ordered, from May 1- May, 8 (morning dosage), and refused Insulin on May 7 (12:30 pm), even after staff explained the benefits and risks.

Both MAR's note an order for staff to monitor (R1's blood pressure every Monday and Thursday, beginning on December 5, 2024, and more often if (R1) desired, and to fax the blood pressure log to (R1's) physician's office. The April MAR notes (R1's) blood pressure was taken on April 3 and 28, as resident was out of the facility from April 4-26. The May MAR notes (R1's) blood pressure was taken and logged on May 1, 5 and 8, prior to (R1) requesting to go to the Emergency Room. The charting notes state (R1) refused PRN medications for "nausea and dry heaves".

Both the DON and Director of Care and Admission stated that (R1) would "refuse medications" and staff Med-Techs would take (R1's) basic vitals and would assist (R1) with "hand to hand" when testing (R1's) blood sugar. The DON stated she would assist with testing (R1's)sugar, if needed, and if (R1) refused insulin. Charting notes indicate (R1) "refuses daily to take insulin" after facility staff received (R1's) lab results back showing blood glucose levels were very high. The DON stated, and charting notes confirm, that the physician increased the pill form of Jardiance 10 mg, on December 12, 2024.

The MARs note medication, Pioglitzaone HCL 15 mg was administered once every morning, as ordered (hold if blood sugar is less than 100), from May 1-8 and Insulin Aspart 100 Unit/ML was ordered with each meal, for diabetes management, starting on May 6, 2025. The MAR notes (R1) refused Insulin on May 7 (12:30 pm) but took took the medication with other meals from May 6-8. *cont on 9099C-2.

SUPERVISORS NAME: Maribeth Senty
LICENSING EVALUATOR NAME: Sabrina Calzada
LICENSING EVALUATOR SIGNATURE:	DATE: 07/22/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/22/2025

LIC9099 (FAS) - (06/04)

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Control Number 59-AS-20250513170952

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: OAKWOOD MEADOWS ASSISTED LIVING	FACILITY NUMBER: 345920108
	VISIT DATE: 07/22/2025

NARRATIVE

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9099C-2.. (R1's) family member stated (R1) "had a blood sugar monitor with a reader but would ignore it while living at home", and would regularly tell him, "they won't take my blood sugar or blood pressure" at the facility.

Based on information obtained, LPA finds the allegation to be UNFOUNDED- A finding that the allegation is unfounded means that the allegation is false, could not have happened, and/or is without a reasonable basis.

Allegation: Staff did not seek medical attention for the resident in a timely manner. The allegation states (R1) had been telling the staff they were 'sick' and needed to go to the hospital approximately 1 week before being sent to the hospital.

Charting notes document that on May 8, 2025, (R1) requested to be sent to the emergency room due to feeling nauseous and having "dry heaves" and was picked up by a non-emergency ambulance transport company at 10:15 am. The prior entry was made on April 21, 2025 and documents (R1) remained at the hospital as of April 21, 2025 after being diagnosed with Acute Hypoxic Respiratory Failure and Chronic Heart Failure and (R1) was treated with new medications prescribed (April 26, 2025). (R1) was transferred from the hospital to skilled nursing before returning to the community on April 26, 2025.

Review of the facility's charting notes documents several times when (R1) requested to be sent out to the emergency room since moving in in October 2024, and was sent out: November 6, 2024; December 10, 2024; December 12, 2024; January 2, 2025; January 22, 2025; January 27, 2025; April 4, 2025; May 5, 2025. The DON stated "if anyone asks to go out, we send them". (R1's) family member stated (R1) didn't like being there and was at a Skilled Nursing Facility for 1.5 years prior to being moved to the facility, commenting "Oakwood Meadows is a nice facility but not a good fit for (R1)". The DON stated that (R1) preferred a medical type environment such as the hospital or skilled nursing rather than Assisted Living.

Based on information obtained, LPA finds the allegation to be UNFOUNDED- A finding that the allegation is unfounded means that the allegation is false, could not have happened, and/or is without a reasonable basis.
Exit interview with the Administrator. Copy of report provided.

SUPERVISORS NAME: Maribeth Senty
LICENSING EVALUATOR NAME: Sabrina Calzada
LICENSING EVALUATOR SIGNATURE:	DATE: 07/22/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/22/2025

LIC9099 (FAS) - (06/04)

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