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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 345920108
Report Date: 10/14/2025
Date Signed: 10/14/2025 05:57:41 PM

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
07/11/2025 and conducted by Evaluator Sabrina Calzada
PUBLIC
COMPLAINT CONTROL NUMBER: 59-AS-20250711115916
FACILITY NAME:OAKWOOD MEADOWS ASSISTED LIVINGFACILITY NUMBER:
345920108
ADMINISTRATOR:TORGERSEN, DANIELFACILITY TYPE:
740
ADDRESS:7241 CANELO HILLS DRTELEPHONE:
(916) 722-2800
CITY:CITUS HEIGHTSSTATE: CAZIP CODE:
95610
CAPACITY:78CENSUS: 73DATE:
10/14/2025
UNANNOUNCEDTIME BEGAN:
12:25 PM
MET WITH:Danny Torgersen, Administrator TIME COMPLETED:
06:00 PM
ALLEGATION(S):
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Staff did not provide adequate meals to resident in care.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Sabrina Calzada arrived unannounced to complete a complaint investigation and deliver findings to a complaint received on July 11, 2025. LPA met with Director of Nursing (DON), Karen Padilla, and the Administrator, Danny Torgersen.

During the investigation, LPA interviewed the administraotor, DON, multiple faciity staff, the lead culinary staff, resident (R1) and (2) of their family members, and several random residents while eating lunch in the dining room. LPA observed food being served to residents on the Assisted Living side during lunch on October 14, 2025 and reviewed meeting notes and observations made during and following a Care Conference held on January 17, 2025. Additional documentation was reviewed related to (R1) including, but not limited to, care plan and physician's report.

The results of the investigation are as follows: **cont on 9099C-1...
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Maribeth Senty
LICENSING EVALUATOR NAME: Sabrina Calzada
LICENSING EVALUATOR SIGNATURE:

DATE: 10/14/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/14/2025
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 9
Control Number 59-AS-20250711115916
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: 10/14/2025
NARRATIVE
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9099C-1...The physician's report notes ((R1) has a diagnosis of Dementia and has some anxiety and depression. The care plan indicates (R1) needs assistance with medications, needs a walker at all times, receives Home Health Services due to weakness of ambulation, and needs minimal assistance with toileting, transferring, dressing and is independent with grooming. Also noted is (R1) requires a Special Diet: Vegetarian.

Allegation: Staff did not provide adequate meals to resident in care. The allegation states in early 2025, resident (R1) was not eating due to horrible food at the facility; (R1) is a vegetarian, and facility staff allegedly knew resident’s dietary care needs.

On 7/11/25, the administrator stated (R1) was at his door every day after moving in, complaining about how they didn't like the food served. The DON confirmed (R1) is "vegetarian", the kitchen is aware, and (R1) gets salads daily, commenting (R1) "is very thin and has lost weight", and the lead chef has started making smoothies.

(R1’s) family member/s stated they believed that (R1) lost weight and became ill due to lack of nutritious foods, and many of the residents stare at the food and do not eat it because staff do not provide special diet plates or food accommodations. (R1) stated in July 2025 they have been vegetarian for 5 years and the facility is serving her salads and other vegetarian foods and does not eat hamburgers or chicken.

LPA reviewed notes from a Care Conference Summary, on 1/17/2025, provided by the administrator noting that (R1) is a vegetarian, has reportedly been served meat, and the family requested more fresh options, such as salads and fruit. Staff stated they are familiar with her preferences. Family willing to visit and encourage eating when intake declines. Immediately following this meeting, the family went to talk to (R1) in their room and observed kitchen staff had served (R1) lunch consisting of deep fried chicken strips, French fries, and a white biscuit.

On September 4, 2025, LPA observed (R1) to be waiting for an alternative to be served for lunch while another resident at the same table had been served. The lead chef stated (R1) has not taken food from other residents lately and is eating their own food, and he purchased Beyond Beef products to give to (R1) since they are a vegetarian. The chef stated staff witnessed (R1) take a BBQ beef sandwich from another resident at the same table and take a bite. *cont on 9099C-2..

SUPERVISORS NAME: Maribeth Senty
LICENSING EVALUATOR NAME: Sabrina Calzada
LICENSING EVALUATOR SIGNATURE:

DATE: 10/14/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/14/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 9
Control Number 59-AS-20250711115916
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: 10/14/2025
NARRATIVE
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9099C-2.. Also on September 4, 2025. LPA discussed these following food concerns, as noted in the Resident Council notes (Aug and July 2025), with the Lead Chef. The Lead Chef stated he regularly attends the meetings and has made changes following resident's complaints, as follows::
  • tough pork chops- substituted with pork loin and sliced for resident portions- more tender than the chops
  • more French fries-residents want the oil/fried French fries- extra crispy- may consider purchasing a few air fryers.
  • too much fish served and more fresh fruit instead of cups

LPA observed two lunch options being served in the Assisted Living unit on October 14, 2025. LPA spoke to many residents, including to (R1) about how they liked lunch and received mixed results if the food was tasty. LPA observed many resident plates to not be finished and the food to be discarded. Many residents indicated they enjoyed the apple crisp dessert. LPA observed (R1) to be eating berries, other fruit cut in small pieces, and oatmeal with seeds brought in by their family member. LPA observed resident (R2) to be eating a grilled cheese sandwich, which was not one of the two options served (tacos with beans and pork with rice, asparagus). (R2) indicated they are vegetarian and staff ask her at every meal what she would like. Today's menu shows a main choice and an alternative choice.

LPA observed the "Black Beans and Vegetable Fajitas" to consist of tortillas, whole black beans and corn, and sour creme and a small amount of sauteed onions/peppers. Many residents complained to LPA that there was no meat or chicken in the "tacos". LPA was told by residents and observed that the "Rosemary Roast Pork" ( with wild rice, pilar and asparagus) was difficult to cut and chew for residents. A third resident indicated he would like to see hash browns served with eggs and bacon for breakfast and has never seen omelettes prepared. LPA observed a fruit basket in the dining room with (3) apples and (1) orange and was told by a family member that residents need soft fruits such as bananas, kiwi, and berries to be served and to cut up fruit that is difficult for residents without teeth to bite. The DON stated the fruit bowl is full in the morning with a variety of foods.

Based on this investigation, the allegation is substantiated- A finding that the complaint is Substantiated means that the allegation is valid because the preponderance of the evidence standard has been met.

Per California Code of Regulations, Title 22, Division 6, Chapter 8, the following (1) citation is issued on the 9099-D page. Exit interview. Copy of report provided.
SUPERVISORS NAME: Maribeth Senty
LICENSING EVALUATOR NAME: Sabrina Calzada
LICENSING EVALUATOR SIGNATURE:

DATE: 10/14/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/14/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 9
Control Number 59-AS-20250711115916
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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/14/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/28/2025
Section Cited
CCR
87555(b)(5)
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87555 General Food Service Requirements (b) The following food service requirements shall apply:
(5) Meals shall consist of an appropriate variety of foods and shall be planned with consideration for cultural and religious background and food habits of residents. This requirement is not met as evidenced by:
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Licensee/Administrator agree to review the menu and ensure there is a vegetarian option listed for each meal.

The Dietary Director will continue to reviewthe daily menu wih the Administrator, and DON, to ensure there is a balance of protein, carbs and vegetables/fruits served at each meal.
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Based on interviews and documentation reviewed, the Licensee did not ensure that resident (R1) was served a vegetarian and healthy meal on January 17, 2025, per their personal preference, which posed a potential health and safety risk to residents in care. (R1) was served deep fried chicken strips, French fries, and cole slaw for lunch.
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Also consider serving cut up fruit and other snacks (cheeses, crackers) so residents can eat without difficulty.

Documentation to be submitted by 10/28/25.
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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: Maribeth Senty
LICENSING EVALUATOR NAME: Sabrina Calzada
LICENSING EVALUATOR SIGNATURE:

DATE: 10/14/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/14/2025
LIC9099 (FAS) - (06/04)
Page: 4 of 9
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
07/11/2025 and conducted by Evaluator Sabrina Calzada
PUBLIC
COMPLAINT CONTROL NUMBER: 59-AS-20250711115916

FACILITY NAME:OAKWOOD MEADOWS ASSISTED LIVINGFACILITY NUMBER:
345920108
ADMINISTRATOR:TORGERSEN, DANIELFACILITY TYPE:
740
ADDRESS:7241 CANELO HILLS DRTELEPHONE:
(916) 722-2800
CITY:CITUS HEIGHTSSTATE: CAZIP CODE:
95610
CAPACITY:78CENSUS: 74DATE:
10/14/2025
UNANNOUNCEDTIME BEGAN:
12:25 PM
MET WITH:Danny Torgersen, Administrator TIME COMPLETED:
06:00 PM
ALLEGATION(S):
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Staff left resident in soiled clothing.
Staff did not shower resident in care.
INVESTIGATION FINDINGS:
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During the investigation, LPA interviewed the administraotor, DON, multiple faciity staff, resident (R1) and (2) of their family members. Documentation was reviewed related to (R1) including, but not limited to, their care plan and physician's report. The results of the investigation for the above (2) allegations are as follows:

Allegation: Staff left resident in soiled clothing. The allegation states in early 2025, resident (R1) was left in urine-soaked clothes.

All staff interviews indicated (R1) is independent with toileting and (R1) has not been observed to have been left in soiled clothing. (R1’s) family member said (R1) was found in soiled clothing one time. The administrator provided LPA with meeting notes from a Care Conference Summary held with (R1's) family,facility staff and others on January 17, 2025. These notes say the family reported increased incontinence, and social workers suggested requesting additional incontinent supplies. The notes also say family member voiced concerns about urine-soaked bedding and being asked by caregiver to take laundry home. The facility agreed to reinforce cleanliness expectations with staff.

Based on information obtained, this allegation is found to be UNSUBSTANTIATED-
*cont on 9099A-C-1..

Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Maribeth Senty
LICENSING EVALUATOR NAME: Sabrina Calzada
LICENSING EVALUATOR SIGNATURE:

DATE: 10/14/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/14/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 5 of 9
Control Number 59-AS-20250711115916
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: 10/14/2025
NARRATIVE
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9099A-C-1... Allegation: Staff did not shower resident in care. The allegation states in early 2025, resident (R1) was not showered. No other details provided.

Staff interviews indicated that resident (R1) would regularly refuse showers and staff would have to try and convince (R1) to take a shower on their scheduled shower days, Wednesdays and Saturdays.

The facility shower schedules reflects (R1) was scheduled to receive a shower on these days, and the care plans notes these days also and resident has a preference showers be given in the morning. Morning shower schedules were reviewed for June 2025. Staff signatures were documented on each Wednesday and Saturday of each week in June to show (R1) received a shower as scheduled. One staff who regularly assisted (R1) with showers stated (R1) also allowed staff to wash their hair.

(R1) confirmed they receive a shower every 2-3 days and is able to do their own shower, and commented additional showers can be requested anytime and staff will give them.

LPA reviewed conference meeting notes from January 17, 2025, which discussed that "staff explained efforts to adjust caregiver assignments and timing when residents are resistant. Showers offered twice weekly due to skin fragility, but clothes are changed daily. Family suggested firmer encouragement from staff".

Based on information obtained, LPA finds this allegation to be UNSUBSTANTIATED A finding that the complaint is Unsubstantiated 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.

Exit interview. Copy of report provided.

SUPERVISORS NAME: Maribeth Senty
LICENSING EVALUATOR NAME: Sabrina Calzada
LICENSING EVALUATOR SIGNATURE:

DATE: 10/14/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/14/2025
LIC9099 (FAS) - (06/04)
Page: 6 of 9
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
07/11/2025 and conducted by Evaluator Sabrina Calzada
PUBLIC
COMPLAINT CONTROL NUMBER: 59-AS-20250711115916

FACILITY NAME:OAKWOOD MEADOWS ASSISTED LIVINGFACILITY NUMBER:
345920108
ADMINISTRATOR:TORGERSEN, DANIELFACILITY TYPE:
740
ADDRESS:7241 CANELO HILLS DRTELEPHONE:
(916) 722-2800
CITY:CITUS HEIGHTSSTATE: CAZIP CODE:
95610
CAPACITY:78CENSUS: 74DATE:
10/14/2025
UNANNOUNCEDTIME BEGAN:
12:25 PM
MET WITH:Danny Torgersen, Administrator TIME COMPLETED:
06:00 PM
ALLEGATION(S):
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Staff overcharged resident in care.
Staff threatened resident in care.
INVESTIGATION FINDINGS:
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During the investigation, LPA interviewed the administraotor, DON, multiple faciity staff, resident (R1) and (2) of their family members. Documentation was reviewed related to (R1's) admission agreement as it pertains to the above allegations. The results of the investigation are as follows:

Allegation: Staff overcharged resident in care. The allegation states facility staff were overcharging resident (R1) in 2023.

Resident’s (R1’s) admission paperwork was reviewed and signed with an effective date of November 24, 2023 and (R1) moved in on November 26, 2023. There is a note that the administrator agreed to reduce the rent payment, effective March 1, 2024, due to the family claiming a monetary hardship and asking for a reduced monthly payment. The administrator stated in July 2025 that the current facility management took over in October 2023, and at the time (R1) moved in, the faciliy admitted residents under a differerent rate structure.
*cont on 9099A-C-1.
Unfounded
Estimated Days of Completion:
SUPERVISORS NAME: Maribeth Senty
LICENSING EVALUATOR NAME: Sabrina Calzada
LICENSING EVALUATOR SIGNATURE:

DATE: 10/14/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/14/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 7 of 9
Control Number 59-AS-20250711115916
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: 10/14/2025
NARRATIVE
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*9099A-C-1.. Documentation provided to the Department shows that a higher monthly amount was charged initially, in November 2023 and then the monthly rate was reduced effective March 1, 2024. The monthly rent amount was decreased on/around May 2024 when a new rate structure began and was increased effective January 1, 2025 and then again on April 1, 2025.

The administrator stated and the Pet Agreement show that the facility never charged to allow (R1) to bring the cat to the facility when moving in. The document was signed on November 27, 2023 by both (R1's) responsible person and a facility manager that there was neither a monthly fee or a one-time fee charged to allow the cat to reside with (R1).

Based on information obtained, LPA finds this allegation to be UNFOUNDED- 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 threatened resident in care. The allegation states (R1) had a cat and staff used to help with cleaning the litter box. On 7/2/2025, (R1’s) family member received a text from the Administrator stating that staff and residents are complaining of the cat’s smell and unsanitary conditions, and the Administrator threatened to evict the resident.

The administrator explained how (R1) was "very anxious the first week (R1) moved in" and the family asked if they could bring (R1's) cat to help them. The administrator stated he told the family that the facility was "not accepting pets at this time, but it would be okay to bring the cat for a little bit". The administrator stated on 7/15/25 that "eviction never came up at all" and (R1) is "doing great currently".

The administrator explained the family signed a Pet Addendum that the facility could not charge for the pet and they never did charge, commenting "I never pushed the issue with the pet". The administrator stated the Addendum stated the cat had to have all vaccines up to date, contact information for the provider, and explained how staff has been taking care of the cat for the last 6 months because (R1) is not able to take care of the cat due to declining.,

*cont on 9099A-C-2..

SUPERVISORS NAME: Maribeth Senty
LICENSING EVALUATOR NAME: Sabrina Calzada
LICENSING EVALUATOR SIGNATURE:

DATE: 10/14/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/14/2025
LIC9099 (FAS) - (06/04)
Page: 8 of 9
Control Number 59-AS-20250711115916
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: 10/14/2025
NARRATIVE
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*9099A-C-2.. On 7/11/25, the administrator stated that he called(R1's) responsible person last week, on a Tuesday or Wednesday, and asked if he could pick up the cat that same day. The administrator indicated he eventually asked if he could pick up the cat by Friday, when the family member indicated he could not pick up the cat on the same day or next day's notice.

The Administrators explained the facility regularly communicated with the responsible person's spouse about bringing in cat food, and commented she "could see mom was declining and could not take care of the cat". The administrator stated again that the admission agreement is very clear- and he "never enforced" the requirements.

The administrator stated at the time (R1) was admitted, there were (20) residents approximately residing in the facility, so he was more flexible in allowing a pet. Meeting notes from January 17, 2025, reflect that staff expressed (R1’s) declining ability to care for the cat, and the family and facility agreed that rehousing the cat may become necessary in future months.

These notes also document (R1’s) increased support needed with ADL’s and scheduling a priority reassessment to determine (R1’s) updated level of care.

Staff interviews revealed that (R1) was able to always feed the cat through early July 2025 but needed assistance towards the end with cleaning the litter box.

The pet agreement was never enforced, and the owner ultimately asked the administrator to inquire if any facility staff members would like to rehome the cat, and one staff did.

There was no evidence found that eviction was ever threatened and a 30- day notice was never issued.

Based on information obtained, LPA finds this allegation to be UNFOUNDED- 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. Copy of report provided.
SUPERVISORS NAME: Maribeth Senty
LICENSING EVALUATOR NAME: Sabrina Calzada
LICENSING EVALUATOR SIGNATURE:

DATE: 10/14/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/14/2025
LIC9099 (FAS) - (06/04)
Page: 9 of 9