315002853-5-1-2025-59-AS-MSEY-DGESTG-20250506140932

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 315002853
Report Date: 05/01/2025
Date Signed: 05/01/2025 02:33:13 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
02/25/2025 and conducted by Evaluator Kevin Mknelly

COMPLAINT CONTROL NUMBER: 59-AS-20250225091336

FACILITY NAME:	SIGNATURE LIVING ON CAMELIA AVENUE		FACILITY NUMBER:	315002853
ADMINISTRATOR:	OCAMPO, JESSE		FACILITY TYPE:	740
ADDRESS:	904 CAMELIA AVE		TELEPHONE:	(916) 899-5880
CITY:	ROSEVILLE	STATE: CA	ZIP CODE:	95678
CAPACITY:	6	CENSUS:	DATE:	05/01/2025
		UNANNOUNCED	TIME BEGAN:	01:05 PM
MET WITH:	Caregiver		TIME COMPLETED:	02:45 PM

ALLEGATION(S):

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Staff do not ensure resident is provided incontinence care in a timely manner

INVESTIGATION FINDINGS:

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On 5/1/25, Licensing Program Analyst (LPA) Kevin Mknelly spoke to caregiver and house manager (by phone) to deliver complaint findings for the above allegation.
LPA reviewed resident records, facility records and conducted extensive interviews. LPA interviewed R1 during this visit.
LPA finds that the allegations cited above are substantiated. Statements by R1 and caregivers found that there had been a prior incident where R1 had incontinence and the caregiver present was not able to do incontinence care alone. The other staff for the shift had checked with R1 before leaving for a break and R1 did not have a care need. While that staff was on break, R1 experienced incontinence. The incontinence care was provided when there were two staff present. This caused a delay in R1's care. The facility has since made changes to staff scheduling and there have been no further incidents.
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. (B) This poses a potential Health and Safety risk, or personal rights violation, to clients/residents in care.
Report reviewed with caregiver . Copy of this report and appeal rights provided.

Substantiated

Estimated Days of Completion:

SUPERVISORS NAME: Maribeth Senty
LICENSING EVALUATOR NAME: Kevin Mknelly
LICENSING EVALUATOR SIGNATURE:	DATE: 05/01/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/01/2025

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

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
02/25/2025 and conducted by Evaluator Kevin Mknelly

COMPLAINT CONTROL NUMBER: 59-AS-20250225091336

FACILITY NAME:	SIGNATURE LIVING ON CAMELIA AVENUE		FACILITY NUMBER:	315002853
ADMINISTRATOR:	OCAMPO, JESSE		FACILITY TYPE:	740
ADDRESS:	904 CAMELIA AVE		TELEPHONE:	(916) 899-5880
CITY:	ROSEVILLE	STATE: CA	ZIP CODE:	95678
CAPACITY:	6	CENSUS:	DATE:	05/01/2025
		UNANNOUNCED	TIME BEGAN:	01:05 PM
MET WITH:	Caregiver		TIME COMPLETED:	02:45 PM

ALLEGATION(S):

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Staff do not provide transfer assistance to resident in care.

INVESTIGATION FINDINGS:

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On 5/1/25, Licensing Program Analyst (LPA) Kevin Mknelly conducted an unannounced complaint investigation visit to deliver the findings for the above allegations and met with Caregiver.

LPA conducted records review and extensive interviews.
LPA is unable to find and or meet the preponderance, per policy.
Records review found that R1 has ability to express their needs. Interviews found that non-urgent needs are addressed by staff timely. There was a period where a hoyer lift did not function properly and that facility staff attempted to resolve the issue timely. It was unable to be determined if facility staff did not transfer R1 at times where a delay was significant to R1's health or safety.
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 caregiver.

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Maribeth Senty
LICENSING EVALUATOR NAME: Kevin Mknelly
LICENSING EVALUATOR SIGNATURE:	DATE: 05/01/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/01/2025

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 4

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
02/25/2025 and conducted by Evaluator Kevin Mknelly

COMPLAINT CONTROL NUMBER: 59-AS-20250225091336

FACILITY NAME:	SIGNATURE LIVING ON CAMELIA AVENUE		FACILITY NUMBER:	315002853
ADMINISTRATOR:	OCAMPO, JESSE		FACILITY TYPE:	740
ADDRESS:	904 CAMELIA AVE		TELEPHONE:	(916) 899-5880
CITY:	ROSEVILLE	STATE: CA	ZIP CODE:	95678
CAPACITY:	6	CENSUS:	DATE:	05/01/2025
		UNANNOUNCED	TIME BEGAN:	01:05 PM
MET WITH:	Caregiver		TIME COMPLETED:	02:45 PM

ALLEGATION(S):

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Staff does not ensure resident is provided a bed in good working condition.
Staff do not ensure medications are properly managed for resident.
Staff do not ensure medications are dispensed in a timely manner.

INVESTIGATION FINDINGS:

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On 5/1/25 , Licensing Program Analyst (LPA) Kevin Mknelly LPA Mknelly arrived and met with Administrator to deliver investigation findings.

LPA reviewed staff records, facility records, and conducted interviews.
LPA finds that facility met Tittle 22 requirements.
The investigation found that bed repairs and medication refill delays were due to receiving timely prescription orders and insurance authorization. Facility staff did proper notification and requests to R1's physician. Facility staff properly managed and administered medications ordered and received.

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: 05/01/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/01/2025

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

Page: 3 of 4

Control Number 59-AS-20250225091336

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: SIGNATURE LIVING ON CAMELIA AVENUE	FACILITY NUMBER: 315002853
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 05/01/2025

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 05/02/2025 Section Cited CCR 87625	1 2 3 4 5 6 7	Managed Incontinence (b)(3) Ensuring that incontinent residents are kept clean and dry and that the facility remains free of odors from incontinence. This requirement was not met based on statements by resident and staff. This posed a potential risk to R1.	1 2 3 4 5 6 7	The licensee has corrected this situation by instituting scheduling changes to ensure adequate number of qualified staff are present for resident needs. This POC is cleared by this visit.
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

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: 05/01/2025

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/01/2025

LIC9099 (FAS) - (06/04)

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