STATEOFCALIFORNIA .

HEALTHANDHUMANSERVICESAGENCY CALIFORNIA DEPARTMENT OF SOCIAL SERVICES

COMMUNITYCARELICENSINGDIVISION
COIWPLAINT INVESTIGATION REPORT COLD Regional Office,
, CA

ThlsJs.anofficialrePort ofan ""announcedvisit/investigation ofa complaint received inourofficeon

and conducted by Evaluator SabrinaCalzada
COMPLAINT CONTROL NUMBER: 27-AS-20180703102622

FACILITY NAME: MEADOW OAKS OF ROSEVILLE FACILITYNUMBER: 317005900

ADMINISTRATOR: TANYSHA BORROMEO FACILITY TYPE: 740
ADDRESS: 930 OAK RIDGE RD TELEPHONE:
CITY: ROSEVILLE
(916) 774-0200
STATE:CA ZIP CODE: 95661
CAPACITY: 108 CENSUS: 93 DATE: 10/22/2018
UNANNOUNCED TIME VISIT BEGAN: 01:45PM
MET WITH: Tanysha Borromeo, Executive Director TIME COMPLETED: 02:30 PM

ALLEGATION(S):
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Staffdidn't know resident whereabouts which resulted in resident sentto hospital
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I IvATION .
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L'censlng program Analyst (LF>A)_Calzada, arrived unannounced on 10/22/18to deliverfindingsonthe
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complaintallegationabove; LPACalzadametwithTanyshaBorromeo^Executive'Dir'ector'
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*on 7;[6^8Lthe.Departmentinitiateda complaintinvestigation intotheallegationthatthefacilitystaffdidn'tknow
theresidentwhereabouts which resulted in resident bemg sent to hospitafand"late7expirmfl"dJueTo'heat'
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exha_ustion. _The Department interviewedj2 staffand 1 resident (R2):'TheDepartmenTalsS r'eviewedresident
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records, personnel records, the facility's Plan ofOperation, andthefacility-s End ofShift-Report dated'6/30/1'8.
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T.he:LPA-rev'ewedthe !ndofshift rePort which indicated that anelderly memory care resident i
^utside tojhe pati0 on 06/30/18. at approximately 9:45 AM after breakfast. Inteiv'iewswit'hthe Executive''
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12 as WGII.
. (S1)on 7/16/18verifiedthistime. Interviewswithfouradditionalcaregivers (S^S5)confi'rmed'this time
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Substantiated
Estimated Days of Completion:
SUPERVISOR'SNAME:Troy Ordonez TELEPHONE:(916) 263-4832
LICENSING EVALUATOR NAME: Sabrina Calzada TELEPHONE: (510) 829-2133
LICENSING EVALUATOR SIGNATURE:

im
I acknowledge receipt ofthis form and understand my appeal rights as explained and received.
DATE: 10/22/2018

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/22/2018

Th -reportmust beavailableatChildCareandGroup Homefacilities for public

LIC9099 (FAS) - (06/04)
Page: 1 of 4
 Control Number 27-AS-20180703102622
STATE OFCALIFORNIA . HEALTH ANDHUMAN SERVICESAGENCY
CALIFORNIADEPARTMENTOF SOCIALSERVICES
COMMUNITYCARE LICENSINGDIVISION
COIVIPLAINTINVESTIGATIONREPORT(Cont) CCLD Regional Office,
, CA

FACILITYNAIVIE:MEADOWOAKSOF ROSEVILLE FACILITY NUMBER: 317005900

VISITDATE: 10/22/2018
NARRATIVE
1
2 r^eccuQt'v.e,D!rec;tor-rs^atedJn. arlLnten/'^wono7/09/18 that staff are exPected to check memory care

3 ^s'd^eve^h^\Ts^aparto^staffsinitialtrainin9^^^^
,

4 i'og^c^eg^e.rs^soconfimedmintere'ewsthatthey^^^
lunch
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monitoring is continued and to
so ensure there are two caregivereaat'airt imes'in^he°m^mo^uca^^
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7 Kar^ogcs^^R^LCckedheckedat
every-hourwhile he was on the memory care patio. The Executive
8 ^rT^t^^. stalc he. oonntheresjd_e^
9 t1ho,f30hlM J;mecaodsshowss2.
wasresPonsible for monitoring"R1 oni/SO/Ts: "S'he"s<ta'tedTnoaan^teS t
10 !£!£Sit?IFs.S^T^0 aSe&dr^T, se^^^
11 ?rat»?^(s. 3.^4MS5^^uld-not-confirm ats2founda replacement'caregiv'er'to'cove^'h^r ^'n^bre'aku^ym
12 l£35KLOJ1^loAM. W2'CMn-CJU ded-thetime. that R1was0^^^^^
13 am. ^^l o^onestaifm.. du^ ,An'"t^/iewwiththeMed-Tech/LVN'(S4;co"nfim:dtha?'sh^"d7dnot'L
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15
s^m^^^T^^T''*''^°^x^^'^'^s"^
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17 Sa°?otrheu^iS?lR^d^S8^^^^^^ sian.
m^ d. s3wentoutside brin9
to R1 back into the
18 ^iSl Sra^^?P1M:3Sl AMJtfonuS.lm.u?:elp^LA
^s^ltela t, 12 :04PM^RLhadbee"-sitiing hours' minutes'ononger'when'temperatu^s'
outside for 1 45
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20 w^re!lcla^ganire^hel9 -3degre^byA^
WFere^lficed.lyaJo^cltLT^her5raph_lwhenR1. ar^
.

21
22 (.F)'.hewas..dehydratedAand had-mult. 'Ple of sunburn (basic'b1iste7bu7ns)7red"ne/ss''on^oadvl. '^w^asu0^
areas
was

23 dlagrosed wlth-a heat_stroke . 6/30/1^and~admitted7ointeu n°s?7e"carecl RU1' eoxp'iFeucl'^57^4^8ayTriSe

on

24 a3SaattecauseofdeathnotedontheDeathcertificatewasheatstrokedue'tS"prolonged^posu'r'^ tosun
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27 continued on 9099C...
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SUPERVISOR'S NAME: Troy Ordonez TELEPHONE: (916) 263-4832
LICENSINGEVALUATORNAME:SabrinaCalzada TELEPHONE: (510) 829-2133
LICENSINGEVALUATORSIGNATURE:

( DATE: 10/22/2018

I acknowledge receipt ofthisform and understand myappeal rights asexplained andreceived.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/22/2018

LIC9099(FAS)- (06/04) Page: 2 of 4

 Control Number27-AS-20180703102622
STATE OFCALIFORNIA - HEALTH AND HUMAN SERVICESAGENCY
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITYCARELICENSINGDIVISION
COMPLAINTINVESTIGATIONREPORT(Cont) CCLDRegional Office,
,CA

FACILITYNAME:MEADOWOAKSOF ROSEVILLE FACILITY NUMBER: 317005900

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/22/2018
DeficiencyType
POC Due Date / DEFICIENCIES
Section Number PLANOFCORRECTIONS(POCs)
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87411 Personnel Requirements - General Licensee and Executive Director conducted an
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Type A (a)Facility personnel shall at all times be in-servicetraining on dehydration on 7/25/18.
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10/24/2018 4
sufficientin numbers, and competentto (Documentationprovidedto CCL). Licensee
Section Cited provide the services necessary to meet and ExecutiveDirectoragreeto require
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OCR resident needs. This requirement is not met as hydration training on new hirees and continue
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evidenced by:
87411(a) 7 the annualtrainingdonefordehydration.

Based on documentation reviewed and Licensee and Executive Director agree to do an

8 interviewswithstaff,stafffailedto provide 8 in-service (10/24/18) on staff coverage
9 adequatecareandsupervisionon6/30/18by 9 expectationsand implementmorefrequent
10 ensuring R1 avoided prolonged exposure tothe 10 status checks during hotter months and will
11 sunandheatandwasbroughtinsidethe " " " 11 post hydrationsignsremindingstaffto regularly
12 facilityon a timelybasis,whichposedan 12 hydrate Licensee and Executive Director'agree
13 immediatehealthandsafetyriskto residentin 13 to providetrainingdocumentation and a plan of
14 care. R-1wasfoundunresponsiveand 14 correction letter by 10/24/18 to CCL by fax.
emergencyservices were called at 12:04 pm.
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aFaciilvu.repteonaclot;r:sc^hses^eten?.deficiency(ies)-onorbeforethep'anof^-ction(POC)duedate,mayresultin
SUPERVISOR'SNAME:TroyOrdonez TELEPHONE:(916)263-4832
LICENSINGEVALUATORNAME:SabrinaCalzada
TELEPHONE: (510) 829-2133
LICENSING EVALUATOR SIGNATURE:

(\ DATE: 10/22/2018

I acknowledgereceiptofthisformandunderstandmyappealrightsasexplainedandreceived.
FACILITYREPRESENTATIVESIGNATURE:

DATE: 10/22/2018

LIC9099(FAS).(06/04)
Page:3 of 4
 Control Number27-AS-20180703102622
STATE OFCALIFORNIA - HEALTH AND HUMAN SERVICESAGENCY CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITYCARE LICENSINGDIVISION
COIWPLAINT INVESTIGATION REPORT (Cont) CCLDRegional Office,
CA

FACILITY NAME: MEADOW OAKS OF ROSEVILLE FACILITT NUMBER: 317005900

VISIT DATE: 10/22/2018
NARRATIVE
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BasSd°n-d?CTentation and interviews. stafffailed to provide adequate care andsupervision byensuring R1
3 ^wldldpr, o'onged expo^re^olhe. s_unandheat_and was brought inside th-elFacilityon~a'timely"basis"ands
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finds the allegation to be SUBSTANTIATED- A
finding that the compra int isSubstantiatedJmeans°that
5 is valid becausethe preponderanceofthe evidencestandardhasbeenmet.
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7 An immediate civil penalty intheamount of$500. 00wasto beassessedforresidentsustainina a
8 s.e-rlous-bod'ly mjurywhlleincare;however. becauseyouhavebeencited'for'repeating'th'esa^e
violation within 12 months,
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an immediate civil penalty of $1, 000. 00 shall be assessed instead"
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11 As.a resLllt oftheresidents death-the violatio" warrants a civil penalty assessment based on health
12 code 1569.49(e). At this time, the civil penalty assessment is under review. LPAwillreturn
13 at a future date to assess a civil penalty if warranted.
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15 Exitinterview done. Copy of report and appeal rights provided.
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SUPERVISOR'S NAME: Troy Ordonez TELEPHONE:(916) 263-4832
LICENSING EVALUATOR NAME: Sabrina Calzada TELEPHONE: (510) 829-2133
LICENSINGEVALUATORSIGNATURE:

DATE: 10/22/2018
ft-^^ ^ T /.
/^ ^
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/22/2018

LIC9099 (FAS) - (06/04) Page: 4 of 4