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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 557005530
Report Date: 10/14/2021
Date Signed: 10/14/2021 01:21:47 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
02/25/2021 and conducted by Evaluator Sarah Hurt
PUBLIC
COMPLAINT CONTROL NUMBER: 27-AS-20210225162657
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: 20DATE:
10/14/2021
UNANNOUNCEDTIME BEGAN:
12:15 PM
MET WITH:Armando Rodriguez, Area Clinical SpecialistTIME COMPLETED:
01:30 PM
ALLEGATION(S):
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Facility did not provide document to authorized representative when requested.
INVESTIGATION FINDINGS:
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Licensing Program Analyst’s (LPA’s) Sarah Hurt and Ruth Wallace arrived at the facility unannounced to conduct a complaint investigation on the above allegation. LPA’s met with LVN Armando Rodriguez and explained the purpose for the visit.

Regarding the allegation that Authorized representative did not receive a copy of the care plan. The facility was cited 05/05/2021 for Personal Rights and was given a plan of correction to keep residents family updated on all care related to resident including any requested documentation.
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.
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Stephenie DoubTELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Sarah HurtTELEPHONE: (916) 879-2602
LICENSING EVALUATOR SIGNATURE:

DATE: 10/14/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/14/2021
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
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 CAREFACILITY NUMBER:
557005530
ADMINISTRATOR:JACOB PRIMEAUFACILITY TYPE:
740
ADDRESS:20420 RAFFERTY CTTELEPHONE:
(209) 533-4822
CITY:SOULSBYVILLESTATE: CAZIP CODE:
95372
CAPACITY:42CENSUS: 20DATE:
10/14/2021
UNANNOUNCEDTIME BEGAN:
12:15 PM
MET WITH:Armando Rodriguez, Area Clinical SpecialistTIME COMPLETED:
01:30 PM
ALLEGATION(S):
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2
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8
9
Resident was injured while in care.
INVESTIGATION FINDINGS:
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Licensing Program Analyst’s (LPA’s) Sarah Hurt and Ruth Wallace arrived at the facility unannounced to conduct a complaint investigation on the above allegation. LPA’s met with LVN Armando Rodriguez and explained the purpose for the visit.

Regarding the allegation that resident was injured while in care. LPA's reviewed documents that confirmed resident had numerous falls in the months of November 2020 through February 2021 when resident was re located to a different facility. Therefore this complaint is SUBSTANTIATED.

The following deficiency was cited per Title 22 Division 6 of the California Code of Regulations. An exit interview was conducted with facility staff and a copy of this report along with appeal rights was provided.
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Stephenie DoubTELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Sarah HurtTELEPHONE: (916) 879-2602
LICENSING EVALUATOR SIGNATURE:

DATE: 10/14/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/14/2021
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 3
Control Number 27-AS-20210225162657
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: 10/14/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
10/15/2021
Section Cited
CCR
87413(a)(1)
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87413(a)(1) Personnel - Operations
(a) In each facility:
(1) When regular staff members are absent, there shall be coverage by personnel with qualifications adequate to perform the assigned tasks.This requirement has not been met as evidenced by:
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Licensee agreed to conduct training on resident falls . Resident moved to another facility beginning 02/12/2021. Licensee will submit proof of training to LPA by POC date.
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LPA's reviewed documents that showed resident had numerous falls and injuries during the months in question. This poses an 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: 10/14/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/14/2021
LIC9099 (FAS) - (06/04)
Page: 3 of 3