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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 312700764
Report Date: 08/01/2024
Date Signed: 08/05/2024 04:27:43 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
This is an official report of an unannounced visit/investigation of a complaint received in our office on
05/17/2024 and conducted by Evaluator Kevin Mknelly
COMPLAINT CONTROL NUMBER: 59-AS-20240517120109
FACILITY NAME:SPLENDOR OAKS SENIOR LIVING 2FACILITY NUMBER:
312700764
ADMINISTRATOR:LEE, KEVINFACILITY TYPE:
740
ADDRESS:6056 BIG BEND DRTELEPHONE:
(916) 297-7141
CITY:ROSEVILLESTATE: CAZIP CODE:
95678
CAPACITY:6CENSUS: 4DATE:
08/01/2024
UNANNOUNCEDTIME BEGAN:
03:35 PM
MET WITH:Care giverTIME COMPLETED:
05:00 PM
ALLEGATION(S):
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Licensee violated admission agreement requirements
Licensee failed to provide records requested
INVESTIGATION FINDINGS:
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On 8/1/24, Licensing Program Analyst (LPA) Kevin Mknelly spoke to caregiver to deliver complaint findings for the above allegation. Caregiver notified Administrator. Designee, Audre Smith arrived to assist.

LPA reviewed resident records, facility records and conducted extensive interviews.
LPA finds that the allegations cited above are substantiated.

Licensee violated admission agreement requirements- In review of records submitted to LPA Mknelly during the investigation it was found that the admission agreement in use by the licensee has not been submitted to and approved by the Department. The signed agreement, however, does identify the fees to be paid for R1’s stay at the home. A review of the fees paid for allowable expenses, the Department finds that a refund is owed to the estate of R1 which was not repaid within 15 days of R1’s passing. R1 was admitted on 3/2/24 and belongings moved out on 4/4/24 . Allowable expenses are the monthly expense for March, daily rate for April,
... report continued
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Maribeth Senty
LICENSING EVALUATOR NAME: Kevin Mknelly
LICENSING EVALUATOR SIGNATURE:

DATE: 08/01/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/01/2024
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 6
Control Number 59-AS-20240517120109
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME: SPLENDOR OAKS SENIOR LIVING 2
FACILITY NUMBER: 312700764
VISIT DATE: 08/01/2024
NARRATIVE
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cable fee and half of the pre-admission charge (as the agreement states half to be reimbursed for less than a 90 day stay). There is discrepancy between what R1’s responsible party says was paid for R1’s stay versus what the licensee’s accounting said was paid. The department does not determine the actual amount only that overpayment was made and a refund is due. The parties involved will seek to resolve the amount owed and seek other means to remediate any discrepancy.

Records review and interview conducted also found that under CCR 87507 – Admission Agreement section (e), a copy shall be provided to the resident and/or responsible party at signing and section (g)(3)(H) a itemized monthly payment statement shall be provided to the resident and/or responsible party, the admission agreement nor the itemized statements were issued to R1’s responsible party promptly when requested.

As a result of this investigation, LPA finds allegation to be (S) Substantiated - A finding that the complaint is Substantiated means that the allegation is valid because the preponderance of the evidence standard has been met. The following deficiencies were cited on 9099-D, per Title 22 Regulations, Division 6. (A)This poses an immediate Health and Safety risk to clients/residents in care. (B) This poses a potential Health and Safety risk, or personal rights violation, to clients/residents in care.

Report reviewed with . Copy of this report and appeal rights provided.
SUPERVISORS NAME: Maribeth Senty
LICENSING EVALUATOR NAME: Kevin Mknelly
LICENSING EVALUATOR SIGNATURE:

DATE: 08/01/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/01/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 6
Control Number 59-AS-20240517120109
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: SPLENDOR OAKS SENIOR LIVING 2
FACILITY NUMBER: 312700764
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/01/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
08/16/2024
Section Cited
CCR
87507(e)
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Admission Agreement- (e) The licensee shall provide a copy of the signed and dated current admission agreement, and all subsequent signed and dated modifications, to the resident or the resident's representative, if any, immediately upon signing the admission agreement or modification. The licensee
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Licensee will submit a statement of procedures that ensure residents or their designee receive copies of signed documents upon admission or request.
POC due by 8/16/24.
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shall provide additional copies to the resident or resident’s representative upon request. This requirement was not met based on interviews that found R1 was not provided a copy at signing not was a copy provided promptly upon request. This potentially violated resident rights.
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Type B
08/15/2024
Section Cited
CCR
1569.652
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Admission Agreement- (c) A refund of any fees paid in advance covering the time after the resident’s personal property has been removed from the facility shall be issued to the individual, individuals, or entity ... responsible for the fees or... to the resident’s estate, within 15 days after
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Licensee will submit a procedure for accounting for and refund money owed to residents or their estate upon fully moving from the facility. Additionally, licensee will submit a statement that the estate of R1 has been refunded money owed.
POC due 8/16/24.
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 the personal property is removed. This requirement was not based on interviews and records reviews finding a refund is doe to R1 and has not been paid within 15 days. This posed a potential to R1's rights.
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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.
SUPERVISORS NAME: Maribeth Senty
LICENSING EVALUATOR NAME: Kevin Mknelly
LICENSING EVALUATOR SIGNATURE:

DATE: 08/01/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/01/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 6
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
This is an official report of an unannounced visit/investigation of a complaint received in our office on
05/17/2024 and conducted by Evaluator Kevin Mknelly
COMPLAINT CONTROL NUMBER: 59-AS-20240517120109

FACILITY NAME:SPLENDOR OAKS SENIOR LIVING 2FACILITY NUMBER:
312700764
ADMINISTRATOR:LEE, KEVINFACILITY TYPE:
740
ADDRESS:6056 BIG BEND DRTELEPHONE:
(916) 297-7141
CITY:ROSEVILLESTATE: CAZIP CODE:
95678
CAPACITY:6CENSUS: 4DATE:
08/01/2024
UNANNOUNCEDTIME BEGAN:
03:35 PM
MET WITH:Care giverTIME COMPLETED:
05:00 PM
ALLEGATION(S):
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Resident's medication mismanaged
Resident diet not followed
INVESTIGATION FINDINGS:
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On 8/1/24, Licensing Program Analyst (LPA) Kevin Mknelly conducted an unannounced complaint investigation visit to deliver the findings for the above allegations and met with designee.

LPA conducted records review and extensive interviews.
LPA is unable to find and or meet the preponderance, per policy.
Resident's medication mismanaged- It was alleged that medications were left unsecured and unattended on one occasion. LPA Mknelly conducted two previous inspections and did not witness such and occurrence. LPA interviewed residents and staff and found no additional evidence of this practice.
Resident diet not followed- R1 was receiving hospice services. As the resident’s condition declined, so too did the residents ability, desire and tastes change. R1 was unable to be interviewed. Hospice records show that when a recommended foods list was provided, R1 was provided foods as directed by hospice based on R1's abilities and preferences.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Maribeth Senty
LICENSING EVALUATOR NAME: Kevin Mknelly
LICENSING EVALUATOR SIGNATURE:

DATE: 08/01/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/01/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 4 of 6
Control Number 59-AS-20240517120109
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME: SPLENDOR OAKS SENIOR LIVING 2
FACILITY NUMBER: 312700764
VISIT DATE: 08/01/2024
NARRATIVE
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As a result of this investigation, LPA finds allegation to be (US)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.

Exit interview with administrator.
SUPERVISORS NAME: Maribeth Senty
LICENSING EVALUATOR NAME: Kevin Mknelly
LICENSING EVALUATOR SIGNATURE:

DATE: 08/01/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/01/2024
LIC9099 (FAS) - (06/04)
Page: 5 of 6
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
This is an official report of an unannounced visit/investigation of a complaint received in our office on
05/17/2024 and conducted by Evaluator Kevin Mknelly
COMPLAINT CONTROL NUMBER: 59-AS-20240517120109

FACILITY NAME:SPLENDOR OAKS SENIOR LIVING 2FACILITY NUMBER:
312700764
ADMINISTRATOR:LEE, KEVINFACILITY TYPE:
740
ADDRESS:6056 BIG BEND DRTELEPHONE:
(916) 297-7141
CITY:ROSEVILLESTATE: CAZIP CODE:
95678
CAPACITY:6CENSUS: 4DATE:
08/01/2024
UNANNOUNCEDTIME BEGAN:
03:35 PM
MET WITH:Care giverTIME COMPLETED:
05:00 PM
ALLEGATION(S):
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Medical care not provided
Licensee failed to report resident death
INVESTIGATION FINDINGS:
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On 8/1/24, Licensing Program Analyst (LPA) Kevin Mknelly LPA Mknelly arrived and met with Administrator , designee to deliver investigation findings.

LPA reviewed staff records, facility records, and conducted interviews.
LPA finds that facility met Tittle 22 requirements.
Medical care not provided- The facility was found to work with Hospice to provide medication for pain relief that was allowable for caregivers to provide and provided R1 pain relief. There was an occasion where R1 needed over the counter medication for diarrhea, once ordered and delivered, Hospice records showed that R1 received the prescribed medication for their condition.
Upon R1's passing, R1's family was notified yet not in a method that was preferred.
This agency has investigated the above complaint allegations. We have found that the complaint is UNFOUNDED, meaning that the allegation was false, could not have happened and/or is without a reasonable basis. We have therefore dismissed the complaint.
Exit interview conducted and report provided.
Unfounded
Estimated Days of Completion:
SUPERVISORS NAME: Maribeth Senty
LICENSING EVALUATOR NAME: Kevin Mknelly
LICENSING EVALUATOR SIGNATURE:

DATE: 08/01/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/01/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 6 of 6