557005530-11-5-2021-27-AS-SDOB-C8VP3A-20211118095712

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 557005530
Report Date: 11/05/2021
Date Signed: 11/05/2021 04:27:03 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
02/25/2021 and conducted by Evaluator Sarah Hurt

PUBLIC

COMPLAINT CONTROL NUMBER: 27-AS-20210225162657

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: 10	DATE:	11/05/2021
		UNANNOUNCED	TIME BEGAN:	02:50 PM
MET WITH:	Tammi Watson, Facility Staff		TIME COMPLETED:	04:30 PM

ALLEGATION(S):

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8
9

Facility did not provide document to authorized representative when requested.

INVESTIGATION FINDINGS:

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2
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5
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10
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13

Licensing Program Analyst (LPA) Sarah Hurt arrived to the facility unannounced to deliver revised findings on the above allegations. LPA met with facility staff Tammy Watson and explained the purpose of today’s visit.

Regarding the allegation facility did not provide document to authorized representative when requested. There are similar allegations made regarding facility not giving requested documents to authorize representatives in a separate complaint. The allegation was investigated and has been substantiated. The facility was already cited on May 10, 2021.The incident did occur therefore, the allegation is SUBSTANTIATED. No further citations will be issued at this time.

An exit interview was conducted, and a copy of this report was left at the facility.

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Stephenie Doub	TELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Sarah Hurt	TELEPHONE: (916) 879-2602
LICENSING EVALUATOR SIGNATURE:	DATE: 11/05/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/05/2021

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 2

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
02/25/2021 and conducted by Evaluator Sarah Hurt

COMPLAINT CONTROL NUMBER: 27-AS-20210225162657

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: 10	DATE:	11/05/2021
		UNANNOUNCED	TIME BEGAN:	02:50 PM
MET WITH:	Tammi Watson, Facility Staff		TIME COMPLETED:	04:30 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Resident was injured while in care.

INVESTIGATION FINDINGS:

1
2
3
4
5
6
7
8
9
10
11
12
13

Licensing Program Analyst (LPA) Sarah Hurt arrived to the facility unannounced to deliver revised findings on the above allegations. LPA met with facility staff Tammi Watson and explained the purpose of today’s visit.

Regarding the allegation resident was injured while in care. Based on document review during this time the resident did have multiple falls. However, the resident’s physicians report does not mention resident needing 24-hour care therefore the facility was not negligent in care of the resident. Therefore, the allegation is deemed UNSUBSTANTIATED. A finding that the complaint is unsubstantiated means that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation did or did not occur, therefore the allegation is unsubstantiated.

An exit interview was conducted and a copy of this report was left at the facility.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Stephenie Doub	TELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Sarah Hurt	TELEPHONE: (916) 879-2602
LICENSING EVALUATOR SIGNATURE:	DATE: 11/05/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/05/2021

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

Page: 2 of 2