557005530-5-3-2021-27-AS-CACL-C2PMST-20210504095227

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 557005530
Report Date: 05/03/2021
Date Signed: 05/03/2021 04:43:25 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
09/24/2020 and conducted by Evaluator Kevin Gould

PUBLIC

COMPLAINT CONTROL NUMBER: 27-AS-20200924161439

FACILITY NAME:	OAK TERRACE MEMORY CARE		FACILITY NUMBER:	557005530
ADMINISTRATOR:	JACOB PRIMEAU		FACILITY TYPE:	740
ADDRESS:	20420 RAFFERTY CT		TELEPHONE:	(209) 533-4822
CITY:	SOULSBYVILLE	STATE: CA	ZIP CODE:	95372
CAPACITY:	42	CENSUS: 22	DATE:	05/03/2021
		UNANNOUNCED	TIME BEGAN:	04:00 PM
MET WITH:	Administrator, Stephanie Olley		TIME COMPLETED:	05:00 PM

ALLEGATION(S):

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Neglect/Lack of Supervision: Facility staff is neglecting clients needs as a result of taking care of staff members children present in the facility.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Kevin Gould made an unannounced tele-inspection to Oak Terrace Memory Care on 5/3/21 at 4:00pm to conclude the investigation of the above allegations and to deliver the findings. LPA spoke with Administrator and together discussed the investigation details.

Based on the interviews and statements obtained during the investigation process, the allegations cannot be substantiated. LPA Gould interviewed 5 staff members, 5 residents and the reporting party (see confidential name list LIC-811 dated 5/3/21) and could not corroborate residents were neglected as a result of the Children's presence at the facility. All staff members interviewed denied that the children interfered with their work or that residents were neglected. All staff denied that children were present in the medication room. all staff identified a staff office or a vacant resident's room. RP states she only saw the children present once and could not provide any evidence that residents were neglected as a result of their presence.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Czarrina A Camilon-Lee	TELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Kevin Gould	TELEPHONE: (619) 672-5924
LICENSING EVALUATOR SIGNATURE:	DATE: 05/03/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/03/2021

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-20200924161439

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: OAK TERRACE MEMORY CARE	FACILITY NUMBER: 557005530
	VISIT DATE: 05/03/2021

NARRATIVE

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Although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. The Department has determined that the allegations of neglect/Lack of supervision are unsubstantiated but if any additional information is received this complaint can be amended and the finding can be changed.

There are no deficiencies noted or cited per California Code Regulation, TITLE 22.

Exit interview was conducted with the facility administrator. Appeal Rights were issued, and a copy of this report was mailed to the facility for signature.

SUPERVISOR'S NAME: Czarrina A Camilon-Lee	TELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Kevin Gould	TELEPHONE: (619) 672-5924
LICENSING EVALUATOR SIGNATURE:	DATE: 05/03/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/03/2021

LIC9099 (FAS) - (06/04)

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