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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 347005529
Report Date: 03/14/2024
Date Signed: 03/14/2024 03:40:19 PM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH 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
10/30/2023 and conducted by Evaluator Arvin Villanueva
COMPLAINT CONTROL NUMBER: 27-AS-20231030082243
FACILITY NAME:MEADOWS SENIOR LIVING, THEFACILITY NUMBER:
347005529
ADMINISTRATOR:ALYSSA SELLERSFACILITY TYPE:
740
ADDRESS:9325 E STOCKTON BLVDTELEPHONE:
(916) 714-3755
CITY:ELK GROVESTATE: CAZIP CODE:
95624
CAPACITY:0CENSUS: DATE:
03/14/2024
UNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Alyssa SellersTIME COMPLETED:
03:45 PM
ALLEGATION(S):
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- Staff do not assist resident with incontinence needs.
- Staff left resident soiled for an extended period of time.
INVESTIGATION FINDINGS:
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On 3/14/24, at 2pm, Licensing Program Analyst (LPA) Arvin Villanueva arrived at this facility to deliver findings of the complaint investigation regarding the allegations noted above. LPA met with Alyssa Sellers, the facility executive director (ED), and explained the purpose of the visit.

Throughout the course of this investigation, LPA Villanueva conducted facility observation, staff and resident interviews and record reviews. Through a record review of Resident1 (R1)'s progress notes dated 5/17/16 to 11/15/23 revealed that R1's needs and services plan was updated semiannually. Per review of the progress notes dated on 7/24/23, author noted that R1 continues to be independent and only requires staff assistance with escort/mobility, bathing and medication administration. Through an interview with ED, LPA was informed that R1 would sometimes refuse to be assisted to the toilet or to get up. Per interview with the facility Care Coordinator (S2), it was stated that in the last 3 months before R1 moved out, R1 has been needing more care.

{Con't to LIC 9099-C...}
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Arvin Villanueva
LICENSING EVALUATOR SIGNATURE:

DATE: 03/14/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/14/2024
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 5
Control Number 27-AS-20231030082243
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME: MEADOWS SENIOR LIVING, THE
FACILITY NUMBER: 347005529
VISIT DATE: 03/14/2024
NARRATIVE
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{...Con't from LIC9099}

Furthermore, S2 informed LPA that staff would check on R1 every 2 to 3 hours and twice during the night shift, but R1 would refuse assistance and at times R1 would not want to get up. Per interview with staff (S3, S4, S5, and S6), they would sometimes witness resident beddings to be wet and/or soiled from accidental incontinence. Interview with randomly selected residents in care (R2 to R8), revealed that their needs are being met at this facility.

Based on the information collected, LPA could not determine if staff do not assist residents with incontinent needs and that staff left resident soiled for an extended period of time. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is UNSUBSTANTIATED.

An exit interview with Alyssa Sellers, ED, was conducted and a copy of this report and appeal rights were provided.
SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Arvin Villanueva
LICENSING EVALUATOR SIGNATURE:

DATE: 03/14/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/14/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 5
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH 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
10/30/2023 and conducted by Evaluator Arvin Villanueva
COMPLAINT CONTROL NUMBER: 27-AS-20231030082243

FACILITY NAME:MEADOWS SENIOR LIVING, THEFACILITY NUMBER:
347005529
ADMINISTRATOR:ALYSSA SELLERSFACILITY TYPE:
740
ADDRESS:9325 E STOCKTON BLVDTELEPHONE:
(916) 714-3755
CITY:ELK GROVESTATE: CAZIP CODE:
95624
CAPACITY:0CENSUS: DATE:
03/14/2024
UNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Alyssa SellersTIME COMPLETED:
03:45 PM
ALLEGATION(S):
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9
Staff speaks to resident in an inappropriate manner.
INVESTIGATION FINDINGS:
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On 3/14/24, at 2pm, Licensing Program Analyst (LPA) Arvin Villanueva arrived at this facility to deliver findings of the complaint investigation regarding the allegations noted above. LPA met with Alyssa Sellers, Executive Director (ED), and explained the purpose of the visit.

Throughout the course of this investigation, LPA Villanueva conducted facility observation, staff and resident interviews, and record reviews.

Through an interview with the ED, it was revealed that there was an incident back in September 2023 where R1 complained of a night staff (S1) that interacted with R1 in an inappropriate manner. Per ED, that interaction made R1 feel scared. According to ED, the staff on duty that night were interviewed, and they informed ED that R1 was refusing to be helped with incontinent care which led S1 stating to R1 that if R1 refused care, they will call emergency personnel to come and help R1.

{Con't to LIC9099-C}
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Arvin Villanueva
LICENSING EVALUATOR SIGNATURE:

DATE: 03/14/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/14/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 3 of 5
Control Number 27-AS-20231030082243
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME: MEADOWS SENIOR LIVING, THE
FACILITY NUMBER: 347005529
VISIT DATE: 03/14/2024
NARRATIVE
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{Con't from LIC9099-A}

Per interview with ED and through record review, the facility’s Human Resources (HR) conducted an investigation of this incident which resulted in a consultation with S1, via oral and written, to review and adhere to the facility’s policies on Resident Relations, making sure communications with resident is expected to be respectful and courteous.

Based on information provided through interviews and record reviews, the Department has investigated the allegation noted and have found the allegation to be SUBSTANTIATED, meaning that there was a preponderance of evidence to prove the allegation occurred as reported.

The following deficiency was observed (see LIC 9099-D) and cited from the California Code of Regulations, Title 22. Failure to correct deficiency may result in civil penalties.

An exit interview with Alyssa Sellers, ED, was conducted and a copy of this report and appeal rights were provided.
SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Arvin Villanueva
LICENSING EVALUATOR SIGNATURE:

DATE: 03/14/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/14/2024
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 27-AS-20231030082243
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: MEADOWS SENIOR LIVING, THE
FACILITY NUMBER: 347005529
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/14/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
03/21/2024
Section Cited
CCR
87468.1(a)(3)
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87468.1(a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (3) To be free from punishment, humiliation, intimidation, abuse, or other actions of a punitive nature…
This requirement is not met as evidenced by:
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• Licensee conducted an investigation and resulted in S1 receiving consultation to review and adhere to the facility’s policies on Resident Relations.
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Based on interviews and record reviews, the licensee was found deficient as evidenced by staff speaking inappropriately when attempting to assist R1 with their care. This posed a potential risk to the Health, Safety, and Personal Rights of the residents in care.
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• Licensee provided staff training on the subject of communicating with residents on Documentation will be provided.
• Licensee to submit a statement of understanding of the regulation cited to the Department by the POC due date.
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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: Stephen Richardson
LICENSING EVALUATOR NAME: Arvin Villanueva
LICENSING EVALUATOR SIGNATURE:

DATE: 03/14/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/14/2024
LIC9099 (FAS) - (06/04)
Page: 5 of 5