557005530-5-5-2021-27-AS-CACL-C2VUHH-20210510153556

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 557005530
Report Date: 05/05/2021
Date Signed: 05/05/2021 03:21:30 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
10/29/2020 and conducted by Evaluator Kevin Gould

PUBLIC

COMPLAINT CONTROL NUMBER: 27-AS-20201029093052

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:	05/05/2021
		UNANNOUNCED	TIME BEGAN:	09:00 AM
MET WITH:	Stephanie Olley, Administrator		TIME COMPLETED:	05:00 PM

ALLEGATION(S):

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Neglect/Lack of Supervision:
1) Facility does not have sufficient staffing.
2) Staff are not providing incontinent care per care plans
3) Staff are not providing assistance with ADLs per care plans
4) Facility not ensuring medications taken per physician's orders
Other:
1) Facility not following program plan to have nurse on duty
2) Administrator not performing duties

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 9:00am 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 cannot be substantiated. LPA was unable to interview RP (see confidential name list LIC-811 dated 5/5/21) and obtain additional information on specific concerns. LPA Gould reviewed resident records including care plans, medication administration records and physician assessment for residents R1, R2, R3, R4 and R5 and conducted interviews. LPA Gould also conducted interview with 4 staff members, none could identify any concerns with the above allegations or provide any evidence to corroborate the allegations. All staff interviewed denied the allegations. Residents interviewed also did not provide any evidence or instances that would corroborate the allegations.

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: 05/05/2021

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)

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Control Number 27-AS-20201029093052

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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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 (indicate the complaint allegation) 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: 05/05/2021

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)

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