557005530-10-8-2021-27-AS-SDOB-C8ULQ3-20211117075651

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 557005530
Report Date: 10/07/2021
Date Signed: 10/08/2021 11:44:47 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
05/27/2021 and conducted by Evaluator Sarah Hurt

COMPLAINT CONTROL NUMBER: 27-AS-20210527144840

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: 20	DATE:	10/07/2021
		UNANNOUNCED	TIME BEGAN:	11:45 AM
MET WITH:	Cathy Helton, Regional Director of Operations		TIME COMPLETED:	01:15 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Residents are not receiving their PM medications as required
Administrator does not provide care, maintain supervision appropriate to residents for facility
Residents have developed pressure injuries and are not receiving medical attention.
Residents have developed UTI's and are not receiving medical attention.

INVESTIGATION FINDINGS:

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

Licensing Program Analyst (LPA) Sarah Hurt arrived at the facility to deliver findings on the above allegations. LPA met with Regional Director of Operations Cathy Helton and explained the purpose for todays visit.

Regarding the allegations staff does not have required training. LPA reviewed the files of several caregivers. All staff does have the required 40 hours of training and required first aid training. Therefore, this complaint is 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

Page 1 of 3..

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: 10/07/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/07/2021

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 3