345920108-5-22-2025-59-AS-MSEY-DGXTK7-20250523144728

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 345920108
Report Date: 05/22/2025
Date Signed: 05/22/2025 06:08:44 PM

Unsubstantiated

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
03/25/2025 and conducted by Evaluator Sabrina Calzada

PUBLIC

COMPLAINT CONTROL NUMBER: 59-AS-20250325082305

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: 74	DATE:	05/22/2025
		UNANNOUNCED	TIME BEGAN:	02:00 PM
MET WITH:	Director of Nursing, Karen Padilla		TIME COMPLETED:	06:00 PM

ALLEGATION(S):

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Staff are not caring for resident's wounds.
Staff are not assisting resident with topical medication.
Staff are allowing resident to sit in soiled bedding.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Sabrina Calzada arrived unannounced to deliver investigative findings for a complaint received on March 25, 2025. LPA met with Director of Nursing, Karen Padilla, and stated the reason for the inspection. LPA later met with Kayla Peria, Care and Admissions Director.

During the investigation, LPA interviewed the Administrator, Director of Nursing, Care and Admissions Director, a care staff and resident (R1). LPA reviewed pertinent documentatation for (R1) including but not limited to the physician's report, hospital discharge paperwork, Medication Administration Record (MAR) for February 2025 and March 2025. The results are as follows:

Resident (R1) moved to the community in December 2023 with a diagnosis of COPD, Chronic Respiratory Failure, and used oxygen. Resident was their own responsible person and could schedule medical appointments.

*cont on 9099C-1..

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Maribeth Senty
LICENSING EVALUATOR NAME: Sabrina Calzada
LICENSING EVALUATOR SIGNATURE:	DATE: 05/22/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/22/2025

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 7

Control Number 59-AS-20250325082305

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: 05/22/2025

NARRATIVE

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9099C-1.. Allegation Staff are not caring for resident's wounds. The allegation states (R1) has open sores all over their body from head to toe that are actively bleeding and staff are not cleaning them and resident has not had a diagnosis for over a year.

On 3/25/25, LPA observed (R1) resting in bed and to have an extensive "rash" on their arms, legs, bottom of the feet and ears. The Director of Nursing (DON) was also present and showed LPA the bottom of resident’s foot that had blisters, explaining the skin condition starts out as blisters but then turns into a rash that is bleeding. (R1) stated she has gone to their health care provider emergency room at least 15 times to treat the rash, indicating they are "trying not to itch, but it still itches and burns". (R1) confirmed they have "nerve damage”, “staff puts on all lotion". and the “lotion helps”. (R1) stated the "rash" started with cyst on the back.

On 3/25/25, the DON stated resident (R1) was at the hospital for (9) hours yesterday due to blisters and has a dermatology appointment on June 2, 2025. The DON confirmed that the hospital ER did not do a skin scrape to test for scabies. The DON confirmed she can only minimally help (R1) with on-line scheduling on her phone and that (R1) has an auto immune condition that could be contributing to the rash.

Hospital documentation shows (R1) went to the emergency room on 3/24/25 and was prescribed two new prescriptions: Clobetasol(Temovate) 0.05 % ointment to be applied to the affected area two times daily for two weeks; and Doxycycline Monohydrate (Avidoxy) 100 mg – 1 tablet to be taken two times daily for 14 days. The hospital discharge paperwork also notes that a follow up dermatology appointment was scheduled on 6/2/25.

A person that knows (R1) stated that the client can’t seem to get an accurate diagnosis as to what the sores are as she has been told they were scabies, but that stated that no one has scabies for over a year.

LPA reviewed hospital documentation showing (R1) visited the emergency room on 3/17/25 for the skin rash and was prescribed a new prescription for Hydro-Cortisone (Hytone) 1% top cream to apply to affected area(s) one to four times daily and given information on rash care. No future appointments were noted on the discharge paperwork.

*cont on 9099C-2..

SUPERVISORS NAME: Maribeth Senty
LICENSING EVALUATOR NAME: Sabrina Calzada
LICENSING EVALUATOR SIGNATURE:	DATE: 05/22/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/22/2025

LIC9099 (FAS) - (06/04)

Page: 2 of 7

Control Number 59-AS-20250325082305

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: 05/22/2025

NARRATIVE

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9099C-2.. Additional hospital documentation reviewed shows (R1) was seen in the emergency room on 2/7/25 with two new prescribed medications: Cetirizine (Zyrtec) 10 mg- 1 tablet to be taken twice daily as needed for itching; and Doxycycline Monohydrate (Avidoxy) 100 mg to take 1 tablet two times daily for seven days. Resident was also provided with information on Cellulitis. No future appointments were noted on the discharge paperwork.

In April 2025, after (R1) was hospitalized, the facility confirmed that the rash was determined to be a staph infection during a resident care conference. On 5/9/25, the DON indicated she received an email earlier that day stating that (R1) would not be returning from the skilled nursing as (R1) was receiving antibiotics to treat the skin rash that "flared up" more due to an auto immune disease (R1) has. The DON confirmed the rash (R1) has had for months is "not scabies.

The Care and Admissions Director stated that resident was sent to the doctor many times, including to the emergency room, and (R1) received many different diagnosis related to the rash, including, cellulitis scabies, lice (on head) and MRSA, and the doctors were not sure what the rash was.

Based on information obtained, LPA finds the 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.

Allegation: Staff are not assisting resident with topical medication. The complaint alleges that resident (R1) can’t move their arms and the staff don’t help by applying topical medication on (R1).

Resident (R1) stated to LPA and the Ombudsman on 3/25/25 that they received a 10-day prescription for the antibiotic, Doxycline Monohydrate 100 mg and for a topical creme, Clobetasol, to be applied two times/day for two weeks. The MAR for March 2025 notes this medication was administered as ordered, and was not given on 3/30/25 and 3/31/25, in the evening, due to resident being out of the facility.

The MAR for February 2025 notes on 2/8/25, the medication, Doxycycline Monohydrate 100 mg tablets were to be given twice daily for seven days and were administered accordingly. Also prescribed on 2/8/25, Hydrocortisone 2.5% ointment, to be applied twice daily to affected area(s) for the rash.
*cont on 9099C-3..

SUPERVISORS NAME: Maribeth Senty
LICENSING EVALUATOR NAME: Sabrina Calzada
LICENSING EVALUATOR SIGNATURE:	DATE: 05/22/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/22/2025

LIC9099 (FAS) - (06/04)

Page: 3 of 7

Control Number 59-AS-20250325082305

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: 05/22/2025

NARRATIVE

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9099C-3.. A third medication was prescribed on 2/8/25 to be applied two times daily to other areas of the rash. MAR shows staff initials for each day/time as prescribed for each of these (3) medications.On 2/23/25, PRN medication for the rash and symptoms was given at 9:04 am- Triamcinolone Acetonide .1% ointment and Cetriizine HCL 10 mg tablet for itching.

Additional PRN medications were given on Feb 2, 5, 8 and 10 for itching related to the rash. One staff stated the Med-Techs are supposed to put cream on the rash and they put it on "here and there"- it seemed like some dosages may have been working and others have not. The DON stated (R1) has a problem with her shoulder and with transferring but has been allowing staff to apply topical crème on.

Based on information obtained, LPA finds the 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.

Allegation: Staff are allowing resident to sit in soiled bedding. The allegation states that the staff don’t clean (R1’s) wounds or change the bed sheets the sheets have old blood stains from the sores.

On 3/26/25, one staff confirmed "the caregivers will change the bedding- we put a towel under her and a washable chux and staff will change the flat/top sheet more". This staff confirmed staff will "often use a fitted sheet too", commenting that "sometimes (R1) will refuse staff to change their sheets, and staff will change their sheets at least once daily when the rash was bleeding".

The Care and Admissions Director stated that all care staff and housekeeping staff are trained to change the sheets every time they notice any stains or soiling, commenting if the sheet is "super soiled", staff will change it right away. The Director explained that staff also use a washable chux, along with the sheets, that is extra large and covers the majority of (R1's) body, and that the chux will be changed more often than the sheets.

The Director explained that (R1) would use oxygen causing her to sweat more and become itchy with the rash, mostly on their neck, shoulders and ears, commenting "we were very careful with (R1)" to ensure they had clean bedding and received showers as often as needed.

*cont on 9099C-4..

SUPERVISORS NAME: Maribeth Senty
LICENSING EVALUATOR NAME: Sabrina Calzada
LICENSING EVALUATOR SIGNATURE:	DATE: 05/22/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/22/2025

LIC9099 (FAS) - (06/04)

Page: 4 of 7

Control Number 59-AS-20250325082305

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: 05/22/2025

NARRATIVE

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9099C-4. In Nov/Dec 2024, staff began requesting (R1) sign when a shower is offered, given or refused since (R1) would often agree initially and then change her mind later.

Based on information obtained, LPA finds the 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: 05/22/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/22/2025

LIC9099 (FAS) - (06/04)

Page: 5 of 7

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
03/25/2025 and conducted by Evaluator Sabrina Calzada

PUBLIC

COMPLAINT CONTROL NUMBER: 59-AS-20250325082305

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: 74	DATE:	05/22/2025
		UNANNOUNCED	TIME BEGAN:	02:00 PM
MET WITH:	Director of Nursing, Karen Padilla		TIME COMPLETED:	06:00 PM

ALLEGATION(S):

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Staff are not meeting residents showering needs.
Staff made inappropriate comments towards resident.

INVESTIGATION FINDINGS:

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During the investigation, LPA interviewed the Administrator, Director of Nursing, Care and Admissions Director, a care staff and resident (R1). LPA reviewed pertinent documentatation for (R1).
The results of the investigation are as follows:

Allegation: Staff are not meeting residents showering needs. The allegation states that (R1) indicated, on 3/18, it had been over a week since (R1’s) last shower.

LPA and Ombudsman Interviewed resident (R1) on 3/26/25 who stated they will "not refuse showers" and she is receiving showers two times per week, as scheduled. The DON added that staff is "trying to shower (R1) more often due to the rash". One staff confirmed she gives showers to (R1) and "always gives the shower in the bathroom", explaining she has been wearing "double gloves" since (R1) has had a rash. This staff confirmed she and (R1) sign the "shower sheet", commenting (R1) "wont refuse with me and if they did, I would wait maybe 10 minutes" and offer the shower again. *cont on 9099A-C-1..

Unfounded

Estimated Days of Completion:

SUPERVISORS NAME: Maribeth Senty
LICENSING EVALUATOR NAME: Sabrina Calzada
LICENSING EVALUATOR SIGNATURE:	DATE: 05/22/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/22/2025

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

Page: 6 of 7

Control Number 59-AS-20250325082305

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: 05/22/2025

NARRATIVE

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9099-A-C-1.. The Administrator confirmed that staff and (R1) are still signing for showers that are given, offered and/or refused. This process was implemented months ago with (R1) since they would often agree to a shower and then later change their mind.

On 4/8/25, the DON stated to LPA that staff were encouraging (R1)to take showers more frequently, the same staff have been working on the hall where (R1) lives, and she is not aware of anyone else with rashes in assisted living.

Based on information obtained, LPA finds this 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 made inappropriate comments towards resident. The allegation states staff (S1) talks about the resident (R1) saying, “ (R1) is a problem child. We’ll get to (R1) when we get to (R1). (R1) is a nuisance.”

One care staff stated "(R1) calls thyself a problem child" and hasn't heard a staff or manager say that. The DON stated she has never heard any staff refer to (R1) or any other resident like that. The Care and Admissions Director stated staff would regularly speak to (R1) in pairs, so there is a witness as to what was said. (R1) never complained to the Admissions Director about any staff making this comment.

Exit interview. Copy of report provided.

SUPERVISORS NAME: Maribeth Senty
LICENSING EVALUATOR NAME: Sabrina Calzada
LICENSING EVALUATOR SIGNATURE:	DATE: 05/22/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/22/2025

LIC9099 (FAS) - (06/04)

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