347005529-11-2-2021-27-AS-KHOS-C8LNF2-20211109092450

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 347005529
Report Date: 11/02/2021
Date Signed: 11/02/2021 12:11:38 PM

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
09/30/2021 and conducted by Evaluator Treana White

PUBLIC

COMPLAINT CONTROL NUMBER: 27-AS-20210930083151

FACILITY NAME:	MEADOWS SENIOR LIVING, THE		FACILITY NUMBER:	347005529
ADMINISTRATOR:	JACOB PRIMEAU		FACILITY TYPE:	740
ADDRESS:	9325 E STOCKTON BLVD		TELEPHONE:	(916) 714-3755
CITY:	ELK GROVE	STATE: CA	ZIP CODE:	95624
CAPACITY:	160	CENSUS: 63	DATE:	11/02/2021
		UNANNOUNCED	TIME BEGAN:	09:20 AM
MET WITH:	Nisha Kaur, Health and Wellness Director/Nurse		TIME COMPLETED:	12:25 PM

ALLEGATION(S):

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Lack of supervision resulting in residents wandering away from facility.

INVESTIGATION FINDINGS:

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On 11/02/2021, Licensing Program Analyst (LPA) T. White conducted an unannounced complaint investigation regarding the above allegation. LPA White discussed the purpose of the visit and the elements of the allegation with Health and Wellness Director/Nurse, Nisha Kaur.

During the course of investigation LPA White interviewed 6 staff members, and collected the following documents on 10/13/2021: Incident Report, In-service staff training, staff schedule. On 11/02/2021, LPA collected, reviewed Physician's Report, and facility videos dated 09/30/2021.

Based on camera video dated 09/30/2021 at 4:57:26 AM, LPA observed Resident #1 (R1) exit the facility building and begin wandering at 5:08:53 AM. At 5:05:03 AM, LPA observed Staff #7 (S7) searching for R1 outside the building. At 05:05:21 AM, S7 continued searching for R1 near the trash area. At 05:06:21AM, LPA observed Staff #6 (S6) searching for R1 outside the facility. At 5:15:14 AM, Staff #8 (S8) found R1 outside the facility door. Based on video, S7 and S8 redirected R1 back to the facility.
Report continues on 9099C.

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Liza King	TELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Treana White	TELEPHONE: (510) 566-9342
LICENSING EVALUATOR SIGNATURE:	DATE: 11/02/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/02/2021

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-20210930083151

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 SENIOR LIVING, THE	FACILITY NUMBER: 347005529
	VISIT DATE: 11/02/2021

NARRATIVE

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Based on Physician's Report, 3 of 3 residents are unable to leave the facility unassisted. Based on staff interviews, 2 of 6 staff members stated there is lack of supervision in the night (Knoc) Shift. Based on S1's interview, R1 eloped from the building and staff responded to the sound of the door.

The following deficiency was observed (see LIC 809D) and cited from the California Code of Regulations, Title 22. Failure to correct deficiency may result in civil penalties.

Exit interview conducted with Health and Wellness Director/Nurse. A copy of report and Appeal Rights given.

SUPERVISOR'S NAME: Liza King	TELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Treana White	TELEPHONE: (510) 566-9342
LICENSING EVALUATOR SIGNATURE:	DATE: 11/02/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/02/2021

LIC9099 (FAS) - (06/04)

Page: 3 of 3

Control Number 27-AS-20210930083151

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 SENIOR LIVING, THE	FACILITY NUMBER: 347005529
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 11/02/2021

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 11/03/2021 Section Cited CCR 87464(f)(1)	1 2 3 4 5 6 7	Basic services shall at a minimum include: (1) Care and supervision as defined in Section 87101(c)(3) and Health and Safety Code 2(c) provides: (c) "Care and supervision" means the facility assumes responsibility for, or provides or promises to provide in the future, ongoing assistance with activities of daily living without which the resident's health would be endangered	1 2 3 4 5 6 7	The facility conducted in-service training to all staff on elopement, supervision, and conducted a drill on 10/01/2021.The facility will update R1's care plan. Facility agreed to submit updated care plan for R1 and a corrective action plan by 11/12/2021.
	8 9 10 11 12 13 14	This requirement was not met as evidenced by: Based on observation, R1's physician's report (LIC 602) stated R1 is unable to leave unassisted. Based on camera video dated 09/30/2021, R1 exited the facility at 05:08:53 AM and S8 found R1 at 5:15:14 AM which poses as an immediate health and safety risk to residents in care.	8 9 10 11 12 13 14
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

SUPERVISOR'S NAME: Liza King	TELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Treana White	TELEPHONE: (510) 566-9342
LICENSING EVALUATOR SIGNATURE:	DATE: 11/02/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/02/2021

LIC9099 (FAS) - (06/04)

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