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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 315920030
Report Date: 10/24/2024
Date Signed: 10/25/2024 04:00:43 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
09/24/2024 and conducted by Evaluator Kevin Mknelly
PUBLIC
COMPLAINT CONTROL NUMBER: 59-AS-20240924091838
FACILITY NAME:DIAMOND OAKS HOME CAREFACILITY NUMBER:
315920030
ADMINISTRATOR:GARCIA, RICHARDFACILITY TYPE:
740
ADDRESS:403 MURRAY CT.TELEPHONE:
(916) 770-4233
CITY:ROSEVILLESTATE: CAZIP CODE:
95678
CAPACITY:6CENSUS: 4DATE:
10/24/2024
UNANNOUNCEDTIME BEGAN:
10:45 AM
MET WITH:Richard GarciaTIME COMPLETED:
11:45 AM
ALLEGATION(S):
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Staff did not provide adequate supervision resulting in residents eloping from facility.
Resident personal rights violated.
INVESTIGATION FINDINGS:
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 On 10/24/24, Licensing Program Analyst (LPA) Kevin Mknelly spoke to Administator, Richard Garcia, to deliver complaint findings for the above allegation.
LPA reviewed resident records, facility records and conducted extensive interviews.
LPA finds that the allegations cited above are substantiated.
Records review found that R1 has a dementia diagnosis with “sundowning” wandering behaviors.
Interviews with neighbors found reports of several instances in the late afternoon where neighbors observed R1 alone walking in the cul-de-sac unaccompanied by staff.
On 9/23/24, R1 was found by a neighbor to be sitting outside on neighbor’s porch furniture. Neighbor reported that when staff arrived, staff approached R1 speaking harshly to R1 stating, “What are you doing here? You need to get up or they are going to call the cops!” S1 grabbed one of R1’s arms and tugged on R1 to get up. S1 was being rough which was concerning to RP. S1 stated that R1 has Alzheimer’s. Another staff (S2) arrived next and appeared very agitated. S2 also spoke harshly to R1 and both staff began tugging on R1 very roughly. - report continued-
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Maribeth Senty
LICENSING EVALUATOR NAME: Kevin Mknelly
LICENSING EVALUATOR SIGNATURE:

DATE: 10/24/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/24/2024
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 3
Control Number 59-AS-20240924091838
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: DIAMOND OAKS HOME CARE
FACILITY NUMBER: 315920030
VISIT DATE: 10/24/2024
NARRATIVE
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Licensee also submitted an incident report for 10/2/24 for R1 leaving unattended and returned to the facility by a neighbor. On 10/2/24, staff did not adhere to 1:1 supervision put in place for R1.

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 Administrator . Copy of this report and appeal rights provided by email.
SUPERVISORS NAME: Maribeth Senty
LICENSING EVALUATOR NAME: Kevin Mknelly
LICENSING EVALUATOR SIGNATURE:

DATE: 10/24/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/24/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 59-AS-20240924091838
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: DIAMOND OAKS HOME CARE
FACILITY NUMBER: 315920030
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/24/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
10/25/2024
Section Cited
CCR
87468.2(a)(4)
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Additional Personal Rights of Residents in Privately Operated Facilities (a)
(4) To care, supervision, and services that meet their individual needs and are delivered by staff that are sufficient in numbers, qualifications, and competency to meet their needs.
This requirement was not met based on
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Licensee has updated procedures and monitoring for R1. There have been no further such incidents.
This citation is cleared by this visit.
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Records and statements that found R1 left without supervision due to staff not monitoring R1 as instucted by R1's plan. This posed an immediate risk to R1.
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Type B
10/25/2024
Section Cited
CCR
87468.1(a)(1)
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Personal Rights of Residents in All Facilities (a)(1) To be accorded dignity in their personal relationships with staff, residents, and other persons. This requirement was not met based on statements that S1 and S2 did not treat R1 with respect when redirecting. This posed a potential risk.
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S1 and S2 no longer work at the home. Licensee has retrained staff. No further correction needed at this time. This citation is cleared by visit.
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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: 10/24/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/24/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 3