345920108-7-1-2025-59-AS-MSEY-DJ8MQ3-20250703094805

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 345920108
Report Date: 07/01/2025
Date Signed: 07/01/2025 05:02:11 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
06/17/2025 and conducted by Evaluator Sabrina Calzada

PUBLIC

COMPLAINT CONTROL NUMBER: 59-AS-20250617165054

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:	07/01/2025
		UNANNOUNCED	TIME BEGAN:	02:40 PM
MET WITH:	Danny Torgersen, Administrator		TIME COMPLETED:	05:00 PM

ALLEGATION(S):

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Licensee is not preventing resident from being scalded by hot water while in care.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Sabrina Calzada arrived unannounced to deliver complaint findings to a complaint received on June 17, 2025, and met with Director of Nursing (DON), Karen Padilla. LPA later met with Administrator, Danny Torgersen, and stated the reason for today's inspection.

During the course of the investigation, LPA interviewed the Maintenance Director, Director of Nursing, (3) care staff and (2) other residents who live in the same wing of the facility as (R1). LPA also observed multiple pages of documentation showing when hot water was tested throughout the building. The results of the investigation are as follows:

The allegation states (R1) has been scalded in the shower for the last two months and has reported the problem but staff have not fixed it, and (R1's) skin is being burned by the scalding water.

*cont on 9099C-1..

Unfounded

Estimated Days of Completion:

SUPERVISORS NAME: Maribeth Senty
LICENSING EVALUATOR NAME: Sabrina Calzada
LICENSING EVALUATOR SIGNATURE:	DATE: 07/01/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/01/2025

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-20250617165054

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: 07/01/2025

NARRATIVE

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9099C-1. Staff interviews conducted on June 18, 2025 revealed that (1) of (4) staff stated that (R1) mentioned the hot water in the shower felt "scorching hot"; however, this staff was not aware of any injuries to (R1) from the hot water. The Director of Nursing stated she is not aware that (R1) complained of the water being too hot or (R1) having any injuries from the hot water.

Two (2) residents were interviewed who reside in the same part of the building that (R1) does. One resident stated she is able to adjust the hot water in the shower by turning the knob. The other resident stated she did not have hot water in the shower for two days and she had to take a cold shower. This resident indicated the problem has been fixed and staff told her a hot water pipe had been broken.

The Maintenance Director stated he checks the hot water temperature throughout the building "every 1-2 weeks", specifically checking the temperature on the heater. The Director explained "each wing of the building has its own water heater" and he does a "cup test to ensure the temperature is less than 120*F". The Director showed LPA the temperature log of room checks and pointed out that (R1's) room was last checked on June 13, 2025, and the temperature was documented as 112*F.

The Maintenance Director stated "(R1) has not complained of any hot water concerns, and the "water temperature for the whole building is set at 120*F", and the only exception is the dishwasher which is part of the septic system". The Director added "(R1) knows me and has no problem telling me if there is a maintenance concern", adding (R1) recently "complained of a lose door knob" in their room. The Director provided specific temperatures of the (5) rooms recently tested as: 112,111,112,112 and 110*F- averaging 111*F.

LPA attempted to speak to (R1) on July 1,2025; however (R1) was out of the facility. LPA checked the hot water temperature in (R1's) sink/room, with staff (S1) present, and found it measured 104.4*F. (S1) explained that (R1) is independent with showering and will place the shower knob on the hottest temperature when warming the water but then does not move the knob to lower the temperature once the water has warmed, as (R1) wants "hot water". (S1) stated she never observed burns on (R1's) skin and most residents will put the shower knob in the middle to achieve the best temperature. (S1) explained that (R1) will often blame their roommate for using water from their sink, causing the water temperature to drop. (S1) stated she has told (R1) dishes are done from 5:30 pm to 9:00 pm, which can lower the hot water temperature.
*cont on 9099C-1..

SUPERVISORS NAME: Maribeth Senty
LICENSING EVALUATOR NAME: Sabrina Calzada
LICENSING EVALUATOR SIGNATURE:	DATE: 07/01/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/01/2025

LIC9099 (FAS) - (06/04)

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Control Number 59-AS-20250617165054

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: 07/01/2025

NARRATIVE

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90099C-2... LPA received communication from (R1) on June 30, 2025 that the Maintenance Director had recently tested the hot water in the shower and placed strips to prevent slipping. Then the Ombudsman tested the hot water, and it was "a bit more than luke warm then", causing the Maintenance Man to adjust the water. (R1) further stated the water pressure is fine now, except for "the water pressure going up and down when someone else is using a sink or shower" and (R1) is trying to adjust their shower time to later in the evening.

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. Copy of report provided.

SUPERVISORS NAME: Maribeth Senty
LICENSING EVALUATOR NAME: Sabrina Calzada
LICENSING EVALUATOR SIGNATURE:	DATE: 07/01/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/01/2025

LIC9099 (FAS) - (06/04)

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