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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 345920216
Report Date: 02/13/2025
Date Signed: 02/13/2025 05:14:48 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
12/17/2024 and conducted by Evaluator Michael Hood
COMPLAINT CONTROL NUMBER: 59-AS-20241217164228
FACILITY NAME:ROSE ARBOR VILLAGEFACILITY NUMBER:
345920216
ADMINISTRATOR:EDWARDS, ANTONETTEFACILITY TYPE:
740
ADDRESS:2001 ROSE ARBOR DRIVETELEPHONE:
(916) 216-8958
CITY:SACRAMENTOSTATE: CAZIP CODE:
95835
CAPACITY:108CENSUS: 39DATE:
02/13/2025
UNANNOUNCEDTIME BEGAN:
11:35 AM
MET WITH:Antonette Edwards, AdministratorTIME COMPLETED:
05:30 PM
ALLEGATION(S):
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Facility does not have adequate staffing resulting in residents’ needs not being met.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Michael Hood arrived at the facility and met with Administrator, Antonette Edwards, to conclude a complaint investigation into the allegation listed above.

During the investigation, LPA conducted interviews, toured the facility, and reviewed documentation pertinent to the investigation.

The results of the investigation are as follows:

Allegation: Facility does not have adequate staffing resulting in residents’ needs not being met.

** Report continued on 9099-C **
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Anthony Perez
LICENSING EVALUATOR NAME: Michael Hood
LICENSING EVALUATOR SIGNATURE:

DATE: 02/13/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/13/2025
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 6
Control Number 59-AS-20241217164228
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: ROSE ARBOR VILLAGE
FACILITY NUMBER: 345920216
VISIT DATE: 02/13/2025
NARRATIVE
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Interview conducted with Administrator indicated that the facility does not have any written policy regarding response times to resident call buttons. Administrator stated that it may take anywhere between thirty (30) seconds to ten (10) minutes for staff to respond to a resident's call button. Administrator stated that there is no standard response time to a resident's call button. Administrator stated that the facility has two (2) caregivers, one (1) nurse, and one (1) med-tech on duty during AM shift, two (2) caregivers with one (1) med-tech or one (1) nurse on duty during PM shift, and two (2) caregivers and one (1) med-tech on duty during NOC shift.

Interview with staff member (S1) indicated that response times to resident call buttons are within at least 15 minutes. S1 stated that residents with incontinence needs are provided assistance as needed and staff know who is in need of incontinence care. Interview with staff member (S2) indicated that there are two (2) caregivers on duty to assist with residents. S2 stated standard response times to call buttons is anywhere between three (3) and five (5) minutes, but a resident might have to wait 20 minutes for a shower or grooming if staff are busy with helping other residents. S2 stated that incontinence care is provided to residents as needed. Interview with staff member (S3) indicated that resident call buttons are responded to as soon as staff receive the call, but a resident may have to wait 10 minutes at the most for care staff to respond to a call button. S3 stated that 50 percent of the community receives assistance with incontinence care as needed.

LPA observed call button logs for residents R3, R4, R5, R6, R7, R8, R9 and R10 from February 4th, 2025 to February 11th, 2025. LPA observed multiple call button response times exceeding 20 minutes and reaching as long as 49 minutes. During visit conduct on February 11th, 2025, LPA toured the interior and exterior of the facility and observed it took 14 minutes to walk the interior and exterior of the facility.

Interview residents R2 and R3 indicated that they didn't receive assistance with laundry from staff for a couple of weeks due to being placed on quarantine for shingles. R2 and R3 indicated that they use a call button to request assistance from staff and response times are longer than preferred. R2 and R3 indicated that R3 sustained a fall and no staff responded to the call button at all. R2 stated that they needed to personally go to the front desk to get staff to assist R3 after falling. Interview with resident R5 indicated that staff are not responding to their call button timely, having waited an hour for staff to respond to their call button. R5 stated that their care needs are not being met timely.
** Report continued on 9099-C **
SUPERVISORS NAME: Anthony Perez
LICENSING EVALUATOR NAME: Michael Hood
LICENSING EVALUATOR SIGNATURE:

DATE: 02/13/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/13/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 6
Control Number 59-AS-20241217164228
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: ROSE ARBOR VILLAGE
FACILITY NUMBER: 345920216
VISIT DATE: 02/13/2025
NARRATIVE
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Interview with resident (R1) indicated that their care needs were not being met at the facility and their calls from their call button were not being answered. R1 stated that it has taken three (3) hours for staff to respond to their call button. R1 indicated that they sustained a fall on December 18th, 2024, resulting in R1 fracturing their elbow and requiring R1 to be sent to a Skilled Nursing Facility. R1 indicated that they used their call button when falling on December 18th, 2024, and waited two (2) hours with no response from staff. R1 stated that they contacted their family member via cell phone after waiting two (2) hours and R1's family contacted EMT for R1. R1 stated that EMT had identified that R1's call button was defective and batteries to R1's call button were dead. Administrator was not able to provide call logs for R1 during the investigation. Interview with relevant party confirmed that R1 sustained a fall on December 18th, 2024 while residing at the facility. Relevant party stated that R1 used their call button around 1:00 AM on December 18th, 2024 to receive assistance with toileting. Relevant party stated that R1 attempted to take themselves to the toilet when they didn't receive a response to their call button. Relevant party stated that R1 fell while attempting to transfer themselves to the toilet and fractured their elbow. Relevant party stated that R1 laid on the floor for two (2) hours before they grabbed their comforted and yanked their cell phone to the floor, spraining their wrist. Relevant party stated that R1 was able to contact their family to contact EMT at 3:00 AM. EMT arrived at the facility to find R1 soiled and R1's call button battery dead. LPA received an Unusual Incident/Injury Report (SIR) dated December 24, 2024 indicating that, on December 18th, 2024, R1 "fell out of bed unwitnessed. [R1] called 911 [themselves]. Fire Dept. came and helped [R1] into wheelchair. Paramedic came and transported [R1] to [hospital] for right hip and elbow pain...Resident was admitted to SNF for Diabetic Keto Acidosis, Fractured elbow, and bruised & sprained wrist, foot and back."

Based on interviews conducted by the department and records reviewed, the preponderance of evidence standards have been met. Therefore, the above allegation is found to be SUBSTANTIATED. Per California Code of Regulations, Title 22, Division 6, Chapter 8, a deficiency is being cited on the attached 9099-D page.

Exit interview was conducted with Administrator. A copy of this report and appeal rights were provided. Signature on these forms acknowledges receipt of these documents.
SUPERVISORS NAME: Anthony Perez
LICENSING EVALUATOR NAME: Michael Hood
LICENSING EVALUATOR SIGNATURE:

DATE: 02/13/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/13/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 6
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
12/17/2024 and conducted by Evaluator Michael Hood
COMPLAINT CONTROL NUMBER: 59-AS-20241217164228

FACILITY NAME:ROSE ARBOR VILLAGEFACILITY NUMBER:
345920216
ADMINISTRATOR:EDWARDS, ANTONETTEFACILITY TYPE:
740
ADDRESS:2001 ROSE ARBOR DRIVETELEPHONE:
(916) 216-8958
CITY:SACRAMENTOSTATE: CAZIP CODE:
95835
CAPACITY:108CENSUS: 39DATE:
02/13/2025
UNANNOUNCEDTIME BEGAN:
11:35 AM
MET WITH:Antonette Edwards, AdministratorTIME COMPLETED:
05:30 PM
ALLEGATION(S):
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Staff are not addressing pests at the facility.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Michael Hood arrived at the facility and met with Administrator, Antonette Edwards, to conclude a complaint investigation into the allegation listed above.

During the investigation, LPA conducted interviews, toured the facility, and reviewed documentation pertinent to the investigation.

The results of the investigation are as follows:

Allegation: Staff are not addressing pests at the facility.

** Report continued on 9099-C **
Unfounded
Estimated Days of Completion:
SUPERVISORS NAME: Anthony Perez
LICENSING EVALUATOR NAME: Michael Hood
LICENSING EVALUATOR SIGNATURE:

DATE: 02/13/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/13/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 4 of 6
Control Number 59-AS-20241217164228
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: ROSE ARBOR VILLAGE
FACILITY NUMBER: 345920216
VISIT DATE: 02/13/2025
NARRATIVE
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Relevant party reported that they observed roaches in a resident's apartment "before October." Facility became licensed on October 1st, 2024.

Interview with Administrator indicated that roaches were observed in a resident's apartment and pest control was received to address pests. LPA observed an invoice for pest control dated December 2nd, 2024 to address "cockroaches." Invoice indicates locations receiving treatment include "exterior area, apartments-interior, kitchen area-interior." Invoice indicates that there were "no findings noted during service." Interviews conducted with residents R2, R3, R4, R5, and R6 did not indicate any pests witnessed on the premises. Interviews with staff member S1, S2, and S3 indicated that the facility addresses any concerns observed regarding pests.

Based on interviews conducted and records reviewed, the above allegation is found 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 was conducted with Administrator. A copy of this report was provided. Signature on these forms acknowledges receipt of these documents.
SUPERVISORS NAME: Anthony Perez
LICENSING EVALUATOR NAME: Michael Hood
LICENSING EVALUATOR SIGNATURE:

DATE: 02/13/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/13/2025
LIC9099 (FAS) - (06/04)
Page: 5 of 6
Control Number 59-AS-20241217164228
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: ROSE ARBOR VILLAGE
FACILITY NUMBER: 345920216
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/13/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
02/14/2025
Section Cited
CCR
87411(a)
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87411 Personnel Requirements - General (a) Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs. This requirement is not met as evidenced by:
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Facility will create a plan to address staff services for residents' needs, including oversight of care being provided to residents and oversight for response times to call buttons. LPA by POC due date of 2/14/2025.
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Based interviews conducted and records reviewed, the facility did not ensure resident care needs were met when resident call buttons were not responsed to in a timely manner, resulting in response times reaching as long as 49 minutes, which poses an immediate health, safety, and personal rights risk to residents in care.
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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: Anthony Perez
LICENSING EVALUATOR NAME: Michael Hood
LICENSING EVALUATOR SIGNATURE:

DATE: 02/13/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/13/2025
LIC9099 (FAS) - (06/04)
Page: 6 of 6