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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 342700369
Report Date: 10/09/2025
Date Signed: 10/09/2025 03:38:45 PM

Substantiated


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
06/03/2025 and conducted by Evaluator Vincent Moleski
PUBLIC
COMPLAINT CONTROL NUMBER: 27-AS-20250603121451
FACILITY NAME:COMMONS AT ELK GROVE, THEFACILITY NUMBER:
342700369
ADMINISTRATOR:MEGGIN CORTEZFACILITY TYPE:
740
ADDRESS:9564 SABRINA LANETELEPHONE:
(916) 683-6833
CITY:ELK GROVESTATE: CAZIP CODE:
95758
CAPACITY:110CENSUS: 73DATE:
10/09/2025
UNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Edward OceguedaTIME COMPLETED:
03:45 PM
ALLEGATION(S):
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Staff do not ensure medications are dispensed as prescribed
INVESTIGATION FINDINGS:
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Licensing Program Analysts (LPAs) Vincent Moleski and Triel Lindstrom arrived unannounced to deliver findings on this complaint investigation. LPA Moleski met with executive director Edward Ocegueda and explained the purpose of the visit.

LPA Moleski reviewed a resident's (R1's) medication administration records. LPA Moleski observed an order for a narcotic painkiller dated April 2025. The order stated that R1 was to receive one half tablet per day as needed for pain. R1 was not to receive more than one half tablet within 24 hours. LPA Moleski reviewed a change order, dated May 9, 2025. R1's prescription was updated such that R1 was ordered to receive two half tablets of the medication per day. However, prior to the change order, on April 27, 2025, R1 received two half tablets of the medication, according to R1's paper narcotic MARs. LPA Moleski asked the facility's health services director (S1) if there were additional prescription orders which would explain this incident. The health services director could not produce any such orders. [continued on 9099-C]
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Vincent Moleski
LICENSING EVALUATOR SIGNATURE:

DATE: 10/09/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/09/2025
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 5
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
06/03/2025 and conducted by Evaluator Vincent Moleski
PUBLIC
COMPLAINT CONTROL NUMBER: 27-AS-20250603121451

FACILITY NAME:COMMONS AT ELK GROVE, THEFACILITY NUMBER:
342700369
ADMINISTRATOR:MEGGIN CORTEZFACILITY TYPE:
740
ADDRESS:9564 SABRINA LANETELEPHONE:
(916) 683-6833
CITY:ELK GROVESTATE: CAZIP CODE:
95758
CAPACITY:110CENSUS: DATE:
10/09/2025
UNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Edward OceguedaTIME COMPLETED:
03:45 PM
ALLEGATION(S):
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Staff do not ensure residents medications are properly managed
Facility is charging resident for services not being provided
INVESTIGATION FINDINGS:
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Licensing Program Analysts (LPAs) Vincent Moleski and Triel Lindstrom arrived unannounced to deliver findings on this complaint investigation. LPA Moleski met with executive director Edward Ocegueda and explained the purpose of the visit.

LPA Moleski interviewed a resident (R1) in June 2025. R1 does not have a diagnosis of dementia or mild cognitive impairment, according to their LIC 602 dated 4/12/24. R1 said they are offered two showers per week, which is required by their care plan. However, R1 said that although they have the option for two showers, they prefer one shower per week. R1 also said that they do receive toileting assistance, and for the most part they do receive all the help they need. R1 said sometimes they do have to wait for assistance, but other times they are offered help when they don't want it. During this interview, R1 appeared clean and hygienic.

[continued on 9099-C]
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Vincent Moleski
LICENSING EVALUATOR SIGNATURE:

DATE: 10/09/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/09/2025
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 5
Control Number 27-AS-20250603121451
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: 10/09/2025
NARRATIVE
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LPA Moleski interviewed five facility staff members regarding R1's care (S1-S5). In interviews, multiple staff members said that R1 sometimes refused care (S1, S2, S3, S4, S5), and that R1 did not always use their call button when they needed assistance (S1, S3). R1's care plan as of June 2025 indicated that R1 was to receive assistance with two showers weekly and total assistance with toileting. However, residents retain the right to refuse any service per 22 CCR Section 87468.1(a)(16).

LPA Moleski reviewed R1's MARs dated between December 2024 and June 2025. LPA Moleski did not observe consistent missed doses or other indicators of systematic mismanagement of R1's medications. In an interview, R1 said they get their medications every day and did not express concerns with missing doses of their medications.

In interviews, two medication technicians (S2, S5) said that there were instances wherein R1's painkillers could not be delivered immediately due to delays in getting their orders refilled. S2 and S5 said that, because the painkiller is a controlled substance, staff were not able to order the medication well in advance, and sometimes the order was delayed before being delivered to R1's pharmacy. LPA Moleski reviewed all progress notes taken during R1's residency at this facility and observed that staff documented their attempts to get orders filled in a timely manner when this occurred.

The department has determined the following as it relates to the allegations that the facility is charging resident for services not being provided and that staff do not ensure residents medications are properly managed:

Based on interviews, record review, and observation, 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 Ocegueda.
SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Vincent Moleski
LICENSING EVALUATOR SIGNATURE:

DATE: 10/09/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/09/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 5
Control Number 27-AS-20250603121451
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: 10/09/2025
NARRATIVE
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S1 pointed out that R1's electronic MARs differ from R1's paper MARs. R1's eMARs show that R1 did not receive any such medication on 4/27/25. However, R1's eMARs do include timestamps showing when medication is passed. These timestamps show that R1 did on occasion receive two half tablets within one 24-hour period during the months of April and May 2025. For example, on April 8, R1 received a half tablet at 10:17 p.m., and received another half tablet on April 9 at 8:46 p.m. On Aril 25, R1 received a half tablet at 9:50 p.m. and received another half tablet on April 26 at 8:13 p.m. On May 3, R1 received a half tablet at 9:37 p.m. and on May 4 received another half tablet at 9:07 p.m. According to R1's eMARs, R1 received their last dose of the painkiller as a once daily PRN on May 11, then began taking the medication again as a twice daily routine medication on the evening on May 13. However, R1's change orders were dated May 9. According to R1's paper narcotic MARs, R1 continued to receive one half tablet each day on May 9-13. The first day R1 received two daily doses of this medication was May 14th, according to both R1's paper MARs and their eMARs.

LPA Moleski observed that R1, in January 2025, had a PRN order on file to take one tablet of the same painkiller twice daily. LPA Moleski observed that R1 received only one tablet for most days the medication was provided during that month. Only on one day, January 5, R1 received two tablets. In an interview R1 said that facility medication technicians told R1 they could only take one tablet, despite being able to take two tablets per day as needed, per their prescription order.

LPA Moleski observed a staff member count out R1's painkiller on 6/4/25 and compared the number of pills missing from the bottle with the doses administered per R1's paper narcotic MARs. The count indicated that the number of doses recorded on the paper MARs was accurate as of that date.

The department has determined the following as it relates to the allegation that staff do not ensure medications are dispensed as prescribed:

Based on record review and interview, 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 22 CCR Section 87465(a)(4). An exit interview was held with Ocegueda. Appeal rights and a copy of this report were left with Ocegueda.
SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Vincent Moleski
LICENSING EVALUATOR SIGNATURE:

DATE: 10/09/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/09/2025
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 27-AS-20250603121451
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: 10/09/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
10/10/2025
Section Cited
CCR
87465(a)(4)
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"(4) The licensee shall assist residents with self-administered medications as needed." This requirement was not met as evidenced by:
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Licensee agrees to provide LPA Moleski with a plan for training as it relates to medication management by POC due date.
vincent.moleski@dss.ca.gov
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Based on record review and interview, a resident's medication was not given as prescribed, which poses an immediate health, safety, and/or personal rights risk.
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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: Stephen Richardson
LICENSING EVALUATOR NAME: Vincent Moleski
LICENSING EVALUATOR SIGNATURE:

DATE: 10/09/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/09/2025
LIC9099 (FAS) - (06/04)
Page: 5 of 5