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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 557005530
Report Date: 05/05/2021
Date Signed: 05/05/2021 06:44:48 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
11/24/2020 and conducted by Evaluator Kevin Gould
PUBLIC
COMPLAINT CONTROL NUMBER: 27-AS-20201124151425
FACILITY NAME:OAK TERRACE MEMORY CAREFACILITY NUMBER:
557005530
ADMINISTRATOR:JACOB PRIMEAUFACILITY TYPE:
740
ADDRESS:20420 RAFFERTY CTTELEPHONE:
(209) 533-4822
CITY:SOULSBYVILLESTATE: CAZIP CODE:
95372
CAPACITY:42CENSUS: 22DATE:
05/05/2021
UNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Stephanie Olley, AdministratorTIME COMPLETED:
06:45 PM
ALLEGATION(S):
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Other:
1) Authorized representative did not receive a copy of the care plan.
2) Staff did not notify authorized representative of residents change in condition.
INVESTIGATION FINDINGS:
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13
Licensing Program Analyst (LPA) Kevin Gould made an unannounced tele-inspection to Oak Terrace Memory Care on 5/5/21 at 2:00am 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 have been corroborated. LPA reviewed files for R1 (see confidential names list, LIC 811 dated 5/5/21) and the facility could not produce a care plan for R1 that was signed by R1's authorized representative. R1 was initially on an all inclusive care plan but was later discontinued and no signed was available for LPA to review in R1's file. Facility could not provide any evidence that a care plan was sent to the Authorized representative.

Page 1 of 2
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Czarrina A Camilon-LeeTELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Kevin GouldTELEPHONE: (619) 672-5924
LICENSING EVALUATOR SIGNATURE:

DATE: 05/05/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/05/2021
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-20201124151425
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: 05/05/2021
NARRATIVE
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LPA Gould Interviewed 5 staff members, 3 of the staff members stated R1 had a noticeable decline and change in condition that included increased depression, agitation and aggression with other residents. The facility requested new medications that RP alleges was not communicated. LPA requested written communication between the facility and R1's authorized representative notifying the authorized representative of R1's change in condition and need for new medications. Facility could not provide written communication prior to the complaint informing authorized representative if the change in condition.

The Department has determined, based on the preponderance of the evidence obtained during this investigation, that the allegation of Other is substantiated but if any additional information is received this complaint can be amended and the finding can be changed.

The following deficiencies are 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.

Page 2 of 2
SUPERVISOR'S NAME: Czarrina A Camilon-LeeTELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Kevin GouldTELEPHONE: (619) 672-5924
LICENSING EVALUATOR SIGNATURE:

DATE: 05/05/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/05/2021
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 27-AS-20201124151425
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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/05/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
05/10/2021
Section Cited
CCR
87468.1
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Personal Rights of Residents in All Facilities: To have their representatives regularly informed by the licensee of activities related to care or services, including ongoing evaluations, as appropriate to their needs. This requirement was not met as evidenced by, the facility could not provide
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Facility will ensure all resident's care plans are signed by the resident or their representatives and provide copies of signed care plans to department. Facility will provide written plan of correction to ensure all future care plans are signed by residents or authorized representatives.
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documentation that R1's representatives were provided an updated care plan for R1 when R1's all inclusive care plan was discontinued by the facility.
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Type B
05/10/2021
Section Cited
CCR
87466
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Observation of the Resident: The licensee shall ensure that residents are regularly observed for changes in physical, mental, emotional and social functioning and that appropriate assistance is provided when such observation reveals unmet needs. When changes such as unusual weight gains or losses or deterioration of mental ability or a physical health condition are observed, the licensee shall ensure that such changes are documented and brought to the attention of the resident's physician and the resident's responsible person, if any.
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Facility will provide in writing the steps the facility will take, including notifying authorized representatives, when a resident is observed to have a change in condition in physical, mental, emotional and social functioning.
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This requirement was not met as evidenced by the facility could not produce any documentation that R1's representatives were notified of a change in condition for R1 that was observed by 3 of 5 staff members which poses a personal rights 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: Czarrina A Camilon-LeeTELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Kevin GouldTELEPHONE: (619) 672-5924
LICENSING EVALUATOR SIGNATURE:

DATE: 05/05/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/05/2021
LIC9099 (FAS) - (06/04)
Page: 3 of 5
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
11/24/2020 and conducted by Evaluator Kevin Gould
PUBLIC
COMPLAINT CONTROL NUMBER: 27-AS-20201124151425

FACILITY NAME:OAK TERRACE MEMORY CAREFACILITY NUMBER:
557005530
ADMINISTRATOR:JACOB PRIMEAUFACILITY TYPE:
740
ADDRESS:20420 RAFFERTY CTTELEPHONE:
(209) 533-4822
CITY:SOULSBYVILLESTATE: CAZIP CODE:
95372
CAPACITY:42CENSUS: 22DATE:
05/05/2021
UNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Stephanie Olley, AdministratorTIME COMPLETED:
06:45 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Neglect/Lack of Supervision:
1) Staff are not providing adequate incontinent care to resident.
2) Insufficient staffing to meet residents needs
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Kevin Gould made an unannounced tele-inspection to Oak Terrace Memory Care on 5/5/21 at 2:00pm 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, 6 residents and the RP (see confidential name list LIC-811 dated 5/5/21) and could not corroborate R1 was not being provided incontinence care. Four staff interviewed described providing incontinence care to R1 and facility documented concerns for infection and contacted R1's physician. Residents interviewed disclosed no concerns with staff care including incontinence care. LPA reviewed staffing schedules and observed a ratio of 1 staff for 7 residents in care. All staff interviewed denied that facility staff could not meet residents needs at current level. Administrators interviewed identified a close sister facility that can support the facility in case of staffing shortages. LPA toured the facility and observed the facility to be clean and sanitary, residents appeared clean.
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Czarrina A Camilon-LeeTELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Kevin GouldTELEPHONE: (619) 672-5924
LICENSING EVALUATOR SIGNATURE:

DATE: 05/05/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/05/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 27-AS-20201124151425
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: 05/05/2021
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
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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-LeeTELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Kevin GouldTELEPHONE: (619) 672-5924
LICENSING EVALUATOR SIGNATURE:

DATE: 05/05/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/05/2021
LIC9099 (FAS) - (06/04)
Page: 5 of 5