342700369-4-7-2025-27-AS-KHOS-DFRTCU-20250415143719

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 342700369
Report Date: 04/07/2025
Date Signed: 04/07/2025 04:28:44 PM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH 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
12/30/2024 and conducted by Evaluator Vincent Moleski

PUBLIC

COMPLAINT CONTROL NUMBER: 27-AS-20241230205302

FACILITY NAME:	COMMONS AT ELK GROVE, THE		FACILITY NUMBER:	342700369
ADMINISTRATOR:	MEGGIN CORTEZ		FACILITY TYPE:	740
ADDRESS:	9564 SABRINA LANE		TELEPHONE:	(916) 683-6833
CITY:	ELK GROVE	STATE: CA	ZIP CODE:	95758
CAPACITY:	110	CENSUS: 82	DATE:	04/07/2025
		UNANNOUNCED	TIME BEGAN:	09:00 AM
MET WITH:	Meggin Cortez		TIME COMPLETED:	04:30 PM

ALLEGATION(S):

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Facility illegally evicted a resident in care.
Staff overcharged a resident in care.
Staff did not ensure resident was provided meals.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Vincent Moleski arrived unannounced to follow up on this complaint investigation. LPA Moleski met with facility administrator Meggin Cortez and explained the purpose of the visit.

This investigation consisted of interviews and record review. LPA Moleski interviewed Cortez, five staff members (S1-S5), and a former resident's responsible party (R1's RP).

LPA Moleski reviewed R1's file. R1 moved into the assisted living section of this facility as of 3/19/2024, according to their admission agreement. R1's initial LIC 602, dated 1/31/24, indicated that R1 had a diagnosis of dementia, but indicated that R1 did not suffer from confusion or disorientation, and that R1 did not exhibit wandering or sundowning behaviors. R1's physician classified R1 as ambulatory.

[continued on 9099-C]

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Vincent Moleski
LICENSING EVALUATOR SIGNATURE:	DATE: 04/07/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/07/2025

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 8

Control Number 27-AS-20241230205302

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: COMMONS AT ELK GROVE, THE	FACILITY NUMBER: 342700369
	VISIT DATE: 04/07/2025

NARRATIVE

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R1's preplacement appraisal also noted a diagnosis of dementia, but also indicated R1 was active and did not require personal help with most activities. The preplacement appraisal does not mention any significant concerns regarding R1's cognitive abilities at the time.

LPA Moleski reviewed narrative charting for R1 dated from their move-in on 3/19/24 to their departure from the facility on 4/9/24. A note on 3/24/24 indicated that R1 had attempted to elope from the facility around 12:38 p.m. According to the note, R1 was escorted back inside from the rear parking lot, where they had been trying to open car doors. In an interview, S1, who escorted R1 back inside, said they heard the door alarm going off and followed R1 out, eventually redirecting R1 and bringing them back into the building without further incident. Another note from 3/24/25 around 10:26 p.m. indicated that R1 had gone out of the building and "walked off towards the road." R1 said they were going for a walk when they were found by a caregiver, who walked R1 back to their room, according to the note. In an interview, S2, the author of the note, confirmed the incident described in the note, and confirmed that R1 was alone outside of the building. A note dated 3/26/24 stated that R1 eloped out through a back door, and was found walking back in through a different set of doors. In an interview S2, the author of this note, said they did not see R1 outside, and by the time they responded to the door alarm R1 was already walking back inside on their own. A note dated 3/28/24 stated that an alarm went off around 3 p.m. R1's friend was present in their room, and told staff that R1 had gone for a walk around the building, per the note. R1 was found by staff walking behind the facility, according to the note. In an interview, S3, the author of the note, confirmed the events described in the note.

R1's LIC 602 did not address whether or not R1 was permitted to be outside the facility unaccompanied by staff. The location on the LIC form used to identify whether or not R1 would be at risk when outside on their own was left blank. However, an assessment for R1, effective as of 3/19/24, indicated that R1 needed total assistance or wheelchair escorts to and from activities and meals, that R1 needed extensive psychosocial supports and behavioral interventions, and that R1 suffered from memory impairment, suggesting that R1 needed continuous supervision to maintain their safety. Based on the above, the facility did not prevent R1's elopements and/or did not accompany or supervise R1 during all elopement incidents, which will be addressed in a separate report.

[continued on 9099-C]

SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Vincent Moleski
LICENSING EVALUATOR SIGNATURE:	DATE: 04/07/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/07/2025

LIC9099 (FAS) - (06/04)

Page: 2 of 8

Control Number 27-AS-20241230205302

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: COMMONS AT ELK GROVE, THE	FACILITY NUMBER: 342700369
	VISIT DATE: 04/07/2025

NARRATIVE

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LPA Moleski reviewed email conversations between facility management staff and R1's RP. On 3/28/24, a manager sent an email to R1's RP requesting a care conference to discuss having a one-on-one caregiver for R1 between 3 p.m. and 9 p.m. due to R1 "leaving the building a number of times" and because R1's use of "the back door has escalated and it is challenging to keep [R1] safe." A manager sent another email to R1's RP on 3/29/24 informing them that the rate for one-on-one caregivers was $35 per hour, and notified them that this would be added to their bill. R1's RP sent an email to Cortez on 4/5/24 while discussing the potential for daytime one-on-one hours. R1's RP said that they "insist the initial 'sundowning' hours from 3pm to 9pm remain until we find an alternative."

LPA Moleski reviewed R1's billing statements. Starting from 3/29/24, R1 was charged for a total of 40 hours of one-on-one care, totaling $1400 at a rate of $35 per hour, which is just under seven days of one-on-one care given the hours of 3 p.m. to 9 p.m. R1's last day at this facility was 4/9/24, 11 days after 3/29/24. In an interview, Cortez said R1 was not charged for all of the one-on-one care that was provided as a courtesy.

Health and Safety Code Section 1569.657(a) states that rates for care may be increased, provided that written notice of the increase providing an explanation of charges is provided to the resident and the resident's responsible party. The requirements of this section appear to have been met based on the emails reviewed by LPA Moleski, given that management explained to R1's RP the rate of the increase and the need for the increase over several emails with sufficient advance notice pursuant to §1569.657(a).

On 4/5/24, Cortez sent an email to R1's RP informing them that the night before, R1 had gone out for a walk in the rain trying to look for a friend's car while accompanied by care staff. A narrative charting note dated 4/4/25 corroborated this incident. Cortez went on to say in this email that R1 "has progressively gotten more agitated with the staff who are working with [R1]" and that "at this point I don't believe [R1] is appropriate for Assisted Living. I feel [R1] would do better in a larger memory care setting ... Of course I would love to retain [R1] in our memory care but we are unfortunately full at this point and I am unsure when we will have an opening ... We of course will continue to have him reside in our Assisted Living until he can find another placement in a memory care facility." On 4/8/24, R1's RP said the following in an email response to Cortez: "Thank you for the suggested alternatives for memory care. We have chosen one of them and will be moving [R1] tomorrow..." In interviews, both Cortez and R1's RP agreed that no eviction notice had been served. [continued on 9099-C]

SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Vincent Moleski
LICENSING EVALUATOR SIGNATURE:	DATE: 04/07/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/07/2025

LIC9099 (FAS) - (06/04)

Page: 3 of 8

Control Number 27-AS-20241230205302

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: COMMONS AT ELK GROVE, THE	FACILITY NUMBER: 342700369
	VISIT DATE: 04/07/2025

NARRATIVE

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LPA Moleski reviewed meal attendance tracking sheets during R1's period of residency, from 3/19/24 to 4/9/24. LPA Moleski observed seven meals for which R1's attendance in the dining room was not recorded. No staff member interviewed was aware of any instances in which R1 had not been provided meals while at the facility. Staff members interviewed indicated that R1 would be brought room service if they did not want to eat down in the dining room. Narrative charting notes for R1 indicated that R1 often preferred to stay in their room for most of the day. According to R1's RP, R1 has severe memory issues and would not be able to recall any events from their time at this facility.

The department has determined the following as it relates to the allegations that the facility illegally evicted a resident in care, that staff overcharged a resident in care, and that staff did not ensure a resident was provided meals:

Based on interviews and record review, the above allegations are UNSUBSTANTIATED, which means that although the allegations may have happened or are valid, there is not a preponderance of the evidence to prove that the alleged violations occurred.

No deficiencies were cited regarding the above allegations. An exit interview was held and a copy of this report was left with Cortez.

SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Vincent Moleski
LICENSING EVALUATOR SIGNATURE:	DATE: 04/07/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/07/2025

LIC9099 (FAS) - (06/04)

Page: 4 of 8

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH 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
12/30/2024 and conducted by Evaluator Vincent Moleski

PUBLIC

COMPLAINT CONTROL NUMBER: 27-AS-20241230205302

FACILITY NAME:	COMMONS AT ELK GROVE, THE		FACILITY NUMBER:	342700369
ADMINISTRATOR:	MEGGIN CORTEZ		FACILITY TYPE:	740
ADDRESS:	9564 SABRINA LANE		TELEPHONE:	(916) 683-6833
CITY:	ELK GROVE	STATE: CA	ZIP CODE:	95758
CAPACITY:	110	CENSUS:	DATE:	04/07/2025
		UNANNOUNCED	TIME BEGAN:	09:00 AM
MET WITH:	Meggin Cortez		TIME COMPLETED:	04:30 PM

ALLEGATION(S):

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Staff did not prevent resident from eloping from the facility.

INVESTIGATION FINDINGS:

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Substantiated

Estimated Days of Completion:

SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Vincent Moleski
LICENSING EVALUATOR SIGNATURE:	DATE: 04/07/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/07/2025

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

LIC9099 (FAS) - (06/04)

Page: 5 of 8

Control Number 27-AS-20241230205302

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: COMMONS AT ELK GROVE, THE	FACILITY NUMBER: 342700369
	VISIT DATE: 04/07/2025

NARRATIVE

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R1's preplacement appraisal also noted a diagnosis of dementia, but also indicated R1 was active and did not require personal help with most activities. The preplacement appraisal does not mention any significant concerns regarding R1's cognitive abilities at the time.

LPA Moleski reviewed narrative charting for R1 dated from their move-in on 3/19/24 to their departure from the facility on 4/9/24. A note on 3/24/24 indicated that R1 had attempted to elope from the facility around 12:38 p.m. According to the note, R1 was escorted back inside from the rear parking lot, where they had been trying to open car doors. In an interview, S1, who escorted R1 back inside, said they heard the door alarm going off and followed R1 out, eventually redirecting R1 and bringing them back into the building without further incident. Another note from 3/24/25 around 10:26 p.m. indicated that R1 had gone out of the building and "walked off towards the road." R1 said they were going for a walk when they were found by a caregiver, who walked R1 back to their room, according to the note. In an interview, S2, the author of the note, confirmed the incident described in the note, and confirmed that R1 was alone outside of the building. A note dated 3/26/24 stated that R1 eloped out through a back door, and was found walking back in through a different set of doors. In an interview S2, the author of this note, said they did not see R1 outside, and by the time they responded to the door alarm R1 was already walking back inside on their own. A note dated 3/28/24 stated that an alarm went off around 3 p.m. R1's friend was present in their room, and told staff that R1 had gone for a walk around the building, per the note. R1 was found by staff walking behind the facility, according to the note. In an interview, S3, the author of the note, confirmed the events described in the note.

R1's LIC 602 did not address whether or not R1 was permitted to be outside the facility unaccompanied by staff. The location on the LIC form used to identify whether or not R1 would be at risk when outside on their own was left blank. However, an assessment for R1, effective as of 3/19/24, indicated that R1 needed total assistance or wheelchair escorts to and from activities and meals, that R1 needed extensive psychosocial supports and behavioral interventions, and that R1 suffered from memory impairment, suggesting that R1 needed continuous supervision to maintain their safety. Based on the above, the facility did not prevent R1's elopements and/or did not accompany or supervise R1 during all elopement incidents in order to ensure R1's health and safety while out of the building. LPA Moleski reviewed email conversations between facility management staff and R1's RP. On 3/28/24, a manager sent an email to R1's RP requesting a care conference to discuss having a one-on-one caregiver for R1 between 3 p.m. and 9 p.m. due to R1 "leaving the building a number of times" and because R1's use of "the back door has escalated and it is challenging to keep [R1] safe." [continued on 9099-C]

SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Vincent Moleski
LICENSING EVALUATOR SIGNATURE:	DATE: 04/07/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/07/2025

LIC9099 (FAS) - (06/04)

Page: 6 of 8

Control Number 27-AS-20241230205302

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: COMMONS AT ELK GROVE, THE	FACILITY NUMBER: 342700369
	VISIT DATE: 04/07/2025

NARRATIVE

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The department has determined the following as it relates to the allegation that staff did not prevent a resident from eloping from the facility:

Based on interview and record review, the above allegation is SUBSTANTIATED. A finding that the complaint allegation is substantiated means that the allegation is valid because the preponderance of evidence standard has been met.

This facility is hereby cited per HSC Section 1569.312(e). An exit interview was held with Cortez. Appeal rights and a copy of this report were left with Cortez.

SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Vincent Moleski
LICENSING EVALUATOR SIGNATURE:	DATE: 04/07/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/07/2025

LIC9099 (FAS) - (06/04)

Page: 7 of 8

Control Number 27-AS-20241230205302

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: COMMONS AT ELK GROVE, THE	FACILITY NUMBER: 342700369
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 04/07/2025

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 04/08/2025 Section Cited HSC 1569.312(e)	1 2 3 4 5 6 7	"Every facility required to be licensed under this chapter shall provide at least the following basic services: Monitoring the activities of the residents while they are under the supervision of the facility to ensure their general health, safety, and well-being. " This requirement was not met as evidenced by:	1 2 3 4 5 6 7	Licensee agrees to send me elopement training sign-in sheets. vincent.moleski@dss.ca.gov
	8 9 10 11 12 13 14	Based on interviews and record review, R1 was not monitored or supervised on several ocassions while out of the building, which poses an immediate health and safety risk.	8 9 10 11 12 13 14
	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: Stephen Richardson
LICENSING EVALUATOR NAME: Vincent Moleski
LICENSING EVALUATOR SIGNATURE:	DATE: 04/07/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/07/2025

LIC9099 (FAS) - (06/04)

Page: 8 of 8