<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 092700840
Report Date: 11/01/2021
Date Signed: 11/01/2021 12:06:41 PM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 520 COHASSET RD., STE. 170
CHICO, CA 95926
This is an official report of an unannounced visit/investigation of a complaint received in our office on
05/20/2021 and conducted by Evaluator Michael Smith
COMPLAINT CONTROL NUMBER: 25-AS-20210520151853
FACILITY NAME:VILLAGE OAKS SENIOR CARE, LLCFACILITY NUMBER:
092700840
ADMINISTRATOR:FOULK, BENJAMIN L.FACILITY TYPE:
740
ADDRESS:1011 ST. ANDREWS DRIVETELEPHONE:
(916) 293-1981
CITY:EL DORADO HILLSSTATE: CAZIP CODE:
95762
CAPACITY:15CENSUS: 9DATE:
11/01/2021
UNANNOUNCEDTIME BEGAN:
11:45 AM
MET WITH:Rod FleemanTIME COMPLETED:
12:15 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Staff administered medication to resident not prescribed by a physician

Staff did not seek medical attention for resident
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Prior to entering the facility, LPA Smith spoke with staff to pre-screen that the facility is COVID free. Analyst also self-screened for having no known symptoms or exposure. Analyst followed facility's screening protocols, wore a mask and maintained distance during the visit. LPA Smith conducted an unannounced complaint visit and met with Rod Fleeman.

Witness observed a notation on a MAR that was crossed out and noticed the resident was reportedly lethargic. No observable reaction or hospitalization. Resident was on hospice and on other narcotic medication. No direct witness that these allegations occurred. The identified party adamantly stated that the medication was never administered to the wrong resident, it was merely charted under the wrong resident and crossed out at the time of notation . Based on this, the allegation is UNSUBSTANTIATED.

As a result of this investigation, LPA finds the allegation that staff administered medication to resident not prescribed by a physician and staff did not seek medical attention for resident to be 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 occurred.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Laura Munoz
LICENSING EVALUATOR NAME: Michael Smith
LICENSING EVALUATOR SIGNATURE:

DATE: 11/01/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/01/2021
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