347004702-5-21-2021-27-AS-KHOS-C3CP5K-20210525110053

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 347004702
Report Date: 05/21/2021
Date Signed: 05/21/2021 11:21:21 AM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

This is an official report of an unannounced visit/investigation of a complaint received in our office on
12/18/2020 and conducted by Evaluator Ruth Wallace

PUBLIC

COMPLAINT CONTROL NUMBER: 27-AS-20201218150049

FACILITY NAME:	MEADOWS AT COUNTRY PLACE, THE		FACILITY NUMBER:	347004702
ADMINISTRATOR:	LIZA SEGUBAN		FACILITY TYPE:	740
ADDRESS:	10 COUNTRY PLACE		TELEPHONE:	(916) 706-3949
CITY:	SACRAMENTO	STATE: CA	ZIP CODE:	95831
CAPACITY:	34	CENSUS: 16	DATE:	05/21/2021
		UNANNOUNCED	TIME BEGAN:	11:00 AM
MET WITH:	Telephone Call - Administrator Liza Seguban		TIME COMPLETED:	11:15 AM

ALLEGATION(S):

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Facility staff are not adequately trained.
Facility is retaining resident that requires a higher level of care.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Ruth Wallace contacted the facility via telephone to conclude a complaint investigation. LPA identified herself and discussed the purpose of the call and the allegations with the Administrator.

Based on LPA interviews with staff, administrator, record review of resident (R1's) medical documents, incident reports and staff training, the facility staff are adequately trained. LPA observed there is no reasonable basis for this complaint. Due to the information gathered LPA finds allegation that Facility staff are not adequately trained is deemed UNFOUNDED. This agency has investigated the allegation noted above and have found that the complaint was unfounded, meaning that the allegation was false, could not have happened and/or was without a reasonable basis. We have therefore, dismissed the complaint.

Continued on 9099-C

Unfounded

Estimated Days of Completion:

SUPERVISOR'S NAME: Stephen Richardson	TELEPHONE: (916) 253-4746
LICENSING EVALUATOR NAME: Ruth Wallace	TELEPHONE: (619) 323-4509
LICENSING EVALUATOR SIGNATURE:	DATE: 05/21/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/21/2021

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

LIC9099 (FAS) - (06/04)

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Control Number 27-AS-20201218150049

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

FACILITY NAME: MEADOWS AT COUNTRY PLACE, THE	FACILITY NUMBER: 347004702
	VISIT DATE: 05/21/2021

NARRATIVE

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Continued from 9099 - Page 2

Based on LPA interviews with staff, administrator, record review of resident (R1's) medical documents, incident reports and staff training. LPA observed there is no reasonable basis for this complaint or evidence of facility retaining resident that requires a higher level of care. All of the staff training for facility was observed by LPA, Hospice care was approved for resident, incident reports showed visits to emergency room and how staff changed level of care for resident after returning. Physician's report showed the decline in R1's condition. The allegation of Facility is retaining resident that requires a higher level of care is deemed UNFOUNDED. This agency has investigated the allegation noted above and have found that the complaint was unfounded, meaning that the allegation was false, could not have happened and/or was without a reasonable basis. We have therefore, dismissed the complaint.

An exit interview was conducted with Administrator via telephone and a copy of this report LIC 9099, LIC 9099-C, LIC 858- Client Records, LIC 811- Confidential Names, and Appeal Rights was provided to the Administrator via email and an electronic email read receipt confirms receiving these documents. Administrator will send 9099 and 9099-C back via email signed to LPA Wallace.

SUPERVISOR'S NAME: Stephen Richardson	TELEPHONE: (916) 253-4746
LICENSING EVALUATOR NAME: Ruth Wallace	TELEPHONE: (619) 323-4509
LICENSING EVALUATOR SIGNATURE:	DATE: 05/21/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/21/2021

LIC9099 (FAS) - (06/04)

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