Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 317005900
Report Date: 10/22/2018
Date Signed 01/30/2019 04:40:52 PM


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office,
, CA
This is an official report of an unannounced visit/investigation of a complaint received in our office on
07/03/2018 and conducted by Evaluator Sabrina Calzada
PUBLIC
COMPLAINT CONTROL NUMBER: 27-AS-20180703102622
FACILITY NAME:MEADOW OAKS OF ROSEVILLEFACILITY NUMBER:
317005900
ADMINISTRATOR:TANYSHA BORROMEOFACILITY TYPE:
740
ADDRESS:930 OAK RIDGE RDTELEPHONE:
(916) 774-0200
CITY:ROSEVILLESTATE: CAZIP CODE:
95661
CAPACITY:108CENSUS: 93DATE:
10/22/2018
UNANNOUNCEDTIME BEGAN:
01:45 PM
MET WITH:Francis Kumar, Resident Services DirectorTIME COMPLETED:
02:30 PM
ALLEGATION(S):
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Staff didn't know resident whereabouts which resulted in resident sent to hospital
INVESTIGATION FINDINGS:
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**Licensing Program Analyst (LPA) Calzada arrived unannounced at the facility on 1/30/19 at 4:30 pm and met with Francis Kumar, Resident Services Director (RSD). The purpose of today's visit is to correct the original report dated 10/22/18 that was inadvertently marked "confidential" instead of "public". LPA obtained a signature from RSD and provided him with a copy of the amended 9099 report. There are no other changes being made to the original report.**

ORIGINAL REPORT BELOW:
Licensing Program Analyst (LPA) Calzada, arrived unannounced on 10/22/18 to deliver findings on the complaint allegation above. LPA Calzada met with Tanysha Borromeo, Executive Director. On 7/6/18, the Department initiated a complaint investigation into the allegation that the facility staff didn't know the resident whereabouts which resulted in resident being sent to hospital and later expiring due to heat exhaustion. The Department interviewed 12 staff and 1 resident (R2). The Department also reviewed resident records, personnel records, the facility’s Plan of Operation, and the facility’s End of Shift Report dated 6/30/18.

The LPA reviewed the End of Shift report which indicated that an elderly memory care resident (R1) went outside to the patio on 06/30/18 at approximately 9:45 AM after breakfast. Interviews with the Executive Director (S1) on 7/16/18 verified this time. Interviews with four additional caregivers (S2-S5) confirmed this time as well.
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Troy OrdonezTELEPHONE: (916) 263-4832
LICENSING EVALUATOR NAME: Sabrina CalzadaTELEPHONE: (510) 829-2133
LICENSING EVALUATOR SIGNATURE:

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

DATE: 10/22/2018
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 4
Control Number 27-AS-20180703102622
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office,
, CA
FACILITY NAME: MEADOW OAKS OF ROSEVILLE
FACILITY NUMBER: 317005900
VISIT DATE: 10/22/2018
NARRATIVE
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The Executive Director stated in an interview on 07/09/18 that staff are expected to check memory care residents every hour. This is a part of staff’s initial training and includes staff documenting checks on the daily log. Caregivers also confirmed in interviews that they must find coverage when taking breaks or going to lunch so monitoring is continued and to ensure there are two caregivers at all times in the memory care unit.

Daily logs show R1 was checked at every hour while he was on the memory care patio. The Executive Director stated staff checked on the resident who was outside from 9:45-11:30 AM and he was given water at 10:30 AM. Time cards shows S2 was responsible for monitoring R1 on 6/30/18. She stated in an interview that she (S2) gave R1 water to avoid dehydration several times. However, interviews of other staff on duty that day (S3, S4, S5) could not confirm that S2 found a replacement caregiver to cover her lunch break from 10:35 to 11:10AM which included the time that R1 was outside. When S2 went to lunch at 10:35 am – 11:10 am, there was only one staff on duty. An interview with the Med-Tech/LVN (S4) confirmed that she did not cover the time when one staff went to lunch. The Med Tech stated in an interview on 9/28/18 that she did not think there was coverage when S2 went to lunch.

Based on the Incident Report dated 6/30/18 and interviews, S2 and S3 went outside to bring R1 back into the building for lunch at 11:30 AM and found him unresponsive. Ambulance records, however, revealed that 911 was called at 12:04PM. R1 had been sitting outside for 1 hours, 45 minutes or longer when temperatures were increasing and reached 93 degrees by 12PM when emergency services were called. The temperatures were verified by a local city weather graph. When R1 arrived at the hospital, his body temperature was 103.4 (F), he was dehydrated, and had multiple areas of sunburn (basic blister burns)/redness on body. R1 was diagnosed with a heat stroke on 6/30/18 and admitted to intensive care. R1 expired on 7/14/18. The immediate cause of death noted on the Death Certificate was heat stroke due to prolonged exposure to sun and heat.


continued on 9099C...
SUPERVISOR'S NAME: Troy OrdonezTELEPHONE: (916) 263-4832
LICENSING EVALUATOR NAME: Sabrina CalzadaTELEPHONE: (510) 829-2133
LICENSING EVALUATOR SIGNATURE:

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

DATE: 10/22/2018
LIC9099 (FAS) - (06/04)
Page: 2 of 4
Control Number 27-AS-20180703102622
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office,
, CA

FACILITY NAME: MEADOW OAKS OF ROSEVILLE
FACILITY NUMBER: 317005900
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/22/2018
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
10/24/2018
Section Cited
CCR
87411(a)
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87411 Personnel Requirements - General (a)Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs. This requirement is not met as evidenced by:
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Licensee and Executive Director conducted an in-service training on dehydration on 7/25/18. (Documentation provided to CCL). Licensee and Executive Director agree to require hydration training on new hirees and continue the annual training done for dehydration.
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Based on documentation reviewed and interviews with staff, staff failed to provide adequate care and supervision on 6/30/18 by ensuring R1 avoided prolonged exposure to the sun and heat and was brought inside the facility on a timely basis, which posed an immediate health and safety risk to resident in care. R-1 was found unresponsive and emergency services were called at 12:04 pm.
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Licensee and Executive Director agree to do an in-service (10/24/18) on staff coverage expectations and implement more frequent status checks during hotter months and will post hydration signs reminding staff to regularly hydrate. Licensee and Executive Director agree to provide training documentation and a plan of correction letter by 10/24/18 to CCL by fax.
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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: Troy OrdonezTELEPHONE: (916) 263-4832
LICENSING EVALUATOR NAME: Sabrina CalzadaTELEPHONE: (510) 829-2133
LICENSING EVALUATOR SIGNATURE:

DATE: 10/22/2018
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: 3 of 4
Control Number 27-AS-20180703102622
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office,
, CA
FACILITY NAME: MEADOW OAKS OF ROSEVILLE
FACILITY NUMBER: 317005900
VISIT DATE: 10/22/2018
NARRATIVE
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Based on documentation and interviews, staff failed to provide adequate care and supervision by ensuring R1 avoided prolonged exposure to the sun and heat and was brought inside the facility on a timely basis and finds the allegation to be SUBSTANTIATED- A finding that the complaint is Substantiated means that the allegation is valid because the preponderance of the evidence standard has been met.

An immediate civil penalty in the amount of $500.00 was to be assessed for resident sustaining a serious bodily injury while in care; however, because you have been cited for repeating the same violation within 12 months, an immediate civil penalty of $1,000.00 shall be assessed instead.

As a result of the residents death, the violation warrants a civil penalty assessment based on health and safety code 1569.49(e). At this time, the civil penalty assessment is under review. LPA will return at a future date to assess a civil penalty if warranted.

Exit interview done. Copy of report and appeal rights provided.
SUPERVISOR'S NAME: Troy OrdonezTELEPHONE: (916) 263-4832
LICENSING EVALUATOR NAME: Sabrina CalzadaTELEPHONE: (510) 829-2133
LICENSING EVALUATOR SIGNATURE:

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

DATE: 10/22/2018
LIC9099 (FAS) - (06/04)
Page: 4 of 4