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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 345002991
Report Date: 06/19/2024
Date Signed: 06/19/2024 01:37:06 PM

Unsubstantiated


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
05/21/2024 and conducted by Evaluator Kevin Mknelly
COMPLAINT CONTROL NUMBER: 59-AS-20240521104511
FACILITY NAME:ROSEVILLE SENIOR LIVINGFACILITY NUMBER:
345002991
ADMINISTRATOR:DOCMANOV, MIODRAGFACILITY TYPE:
740
ADDRESS:6573 ROSE BRIDGE DRTELEPHONE:
(916) 678-2908
CITY:ROSEVILLESTATE: CAZIP CODE:
95678
CAPACITY:6CENSUS: 4DATE:
06/19/2024
UNANNOUNCEDTIME BEGAN:
12:40 PM
MET WITH:CaregiverTIME COMPLETED:
01:45 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Staff hit a resident while in care
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
 On 6/19/24, Licensing Program Analyst (LPA) Kevin Mknelly conducted an unannounced complaint investigation visit to deliver the findings for the above allegations and met with caregiver. The administrator was notified and arrived at the facility.
LPA conducted records review and interviews with caregivers and R1.
LPA is unable to find and or meet the preponderance, per policy.
Records showed R1 to have dementia and interviews found R1 to be regularly exit seeking. Interviews with staff found no staff reported to have hit R1 nor observed others to have hit R1. Interview with R1 found her to express wishes to go home and not recall where she currently resided or why she needed assistance. While LPA was present on 5/22/24 R1 vacillated between wishing to leave and saying she loved the staff. R1 moved from this facility to another RCFE until R1 can move home with family.
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. Copy of the report provided.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Maribeth Senty
LICENSING EVALUATOR NAME: Kevin Mknelly
LICENSING EVALUATOR SIGNATURE:

DATE: 06/19/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/19/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
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