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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 557005530
Report Date: 12/02/2021
Date Signed: 12/02/2021 09:06:36 PM


Document Has Been Signed on 12/02/2021 09:06 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		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 CAREFACILITY NUMBER:
557005530
ADMINISTRATOR:ILONA ROZA CORPUSFACILITY TYPE:
740
ADDRESS:20420 RAFFERTY CTTELEPHONE:
(209) 533-4822
CITY:SOULSBYVILLESTATE: CAZIP CODE:
95372
CAPACITY:42CENSUS: 7DATE:
12/02/2021
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Regional Director of Operations Cathy HeltonTIME COMPLETED:
01:15 PM
NARRATIVE
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Licensing Program Analyst (LPA) Sarah Hurt arrived at the facility unannounced on 12/02/2021 at 10:30 a.m. to conduct a Case Management visit. LPA met with Regional Director of Operations Cathy Helton and explained the purpose for today’s visit. The facility capacity is 42 and current census is 7.

LPA observed kitchen, dining, resident bedrooms, and main living areas. A meeting was conducted through Microsoft Teams on 10/22/2021 to discuss ongoing staffing shortages at the facility and possible temporary closure. It was decided during the meeting the facility representatives would submit to licensing a formal letter requesting to temporarily relocate residents to other Milestone facilities, and an official plan detailing how the facility plans to ensure adequate staffing by noon on 10/25/2021. LPA did not receive a detailed formal plan on relocation of residents or staffing. During a visit to the facility on 11/05/2021 LPA met with facility staff Tammy Watson who explained there was only 9 residents currently living at the facility as 5 residents had already been relocated as they are preparing to close the facility and have already begun the process of transferring out residents. Administrator Jacob Primeau sent a roster of the residents who elected to transfer on 11/16/2021 and attached the letter sent to resident families initiating the transfer. LPA interviewed three resident families by phone on 11/24/2021. The families all stated they were not given enough time to find a new facility for their family member. The families also stated they were basically told the facility is closing due to staff shortages and it came across as if they had no other choice but to transfer their family member to The Meadows. The families said later they would speak with another staff member that would tell them it was only temporary, and the resident would return to the facility once more staffing was hired. The family members all agreed the communication from the facility and intention was unclear.


The following deficiencies were cited per Title 22 Division 6 of the California Code of Regulations. An exit interview was conducted with Regional Director of Operations Cathy Helton and a copy of this report along with appeal rights was provided.
SUPERVISOR'S NAME: Stephenie DoubTELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Sarah HurtTELEPHONE: (916) 879-2602
LICENSING EVALUATOR SIGNATURE:
DATE: 12/02/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/02/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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Document Has Been Signed on 12/02/2021 09:06 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/02/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Request Denied
Type A
12/03/2021
Section Cited

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87468.2 Additional Personal Rights of Residents in Privately Operated Facilities (20) To be protected from involuntary transfers, discharges, and evictions. A licensee shall not involuntarily transfer or evict residents for reasons other than those permitted by state law or regulations and shall comply with all eviction and relocation protections for residents. For purposes of this paragraph, "involuntary" means a transfer, discharge, or eviction that is initiated by the licensee, not by the resident.
This requirement has not been met as evidenced by:
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Based on observation, interviews, and record review the licensee initiated the resident transfers, and did not comply with eviction regulations which pose an immediate health and safety risk to residents in care.
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Deficiency Dismissed
Type A
12/03/2021
Section Cited

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87207 False Claims
No licensee, officer or employee of a licensee shall make or disseminate any false or misleading statement regarding the facility or any of the services provided by the facility.
This requirement has not been met as evidenced by:
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Based on observation, and records reviewed the Licensee sent a letter to resident families with the statement “we have notified the State of California, Department of Social Services and will work with their office to ensure communication, support and and follow up complies with the regulation set forth for an interim transfer. “This is a false statement. The Department of Social Services was not aware of any “temporary” transfer of residents which poses an immediate health and safety 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.
SUPERVISOR'S NAME: Stephenie DoubTELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Sarah HurtTELEPHONE: (916) 879-2602
LICENSING EVALUATOR SIGNATURE:
DATE: 12/02/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/02/2021
LIC809 (FAS) - (06/04)
Page: 2 of 3


Document Has Been Signed on 12/02/2021 09:06 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/02/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Deficiency Dismissed
Type A
12/03/2021
Section Cited

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87205 Accountability of Licensee Governing Body (a) The licensee, whether an individual or other entity, shall exercise general supervision over the affairs of the licensed facility and establish policies concerning its operation in conformance with these regulations and the welfare of the individuals it serves. This requirement has not been met as evidenced by:
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Based on observation, record review, and interviews the licensee is not conforming with established policies and regulations with the recent sudden facility initiated transfer of residents to other facilities which poses and immediate 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.
SUPERVISOR'S NAME: Stephenie DoubTELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Sarah HurtTELEPHONE: (916) 879-2602
LICENSING EVALUATOR SIGNATURE:
DATE: 12/02/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/02/2021
LIC809 (FAS) - (06/04)
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