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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 345920108
Report Date: 01/03/2025
Date Signed: 01/03/2025 04:47:10 PM

Unfounded


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
12/31/2024 and conducted by Evaluator Sabrina Calzada
PUBLIC
COMPLAINT CONTROL NUMBER: 59-AS-20241231154627
FACILITY NAME:OAKWOOD MEADOWS ASSISTED LIVINGFACILITY NUMBER:
345920108
ADMINISTRATOR:TORGERSEN, DANIELFACILITY TYPE:
740
ADDRESS:7241 CANELO HILLS DRTELEPHONE:
(916) 722-2800
CITY:CITUS HEIGHTSSTATE: CAZIP CODE:
95610
CAPACITY:78CENSUS: 65DATE:
01/03/2025
UNANNOUNCEDTIME BEGAN:
01:10 PM
MET WITH:Danny Torgersen, Administrator TIME COMPLETED:
03:15 PM
ALLEGATION(S):
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Facility withheld residents medications upon move out.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Sabrina Calzada arrived unannounced to commence and conclude a complaint investigation. LPA met with Danny Torgersen, Administrator, and Karen Padilla, Director of Nursing, and stated the reason for the inspection.

During today's inspection, LPA interviewed the Administrator, Director of Nursing (DON) and (1) Med-Tech staff who conducted the discharge with prior resident (R1) on 12/30/24. Documentation related to (R1) was reviewed including the physician's report, charting notes, physician's orders, December Medication Administration Record (MAR), and medications released upon discharge.

The results of the investigation are as follows:

cont on 9099C-1..
Unfounded
Estimated Days of Completion:
SUPERVISORS NAME: Maribeth Senty
LICENSING EVALUATOR NAME: Sabrina Calzada
LICENSING EVALUATOR SIGNATURE:

DATE: 01/03/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/03/2025
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 3
Control Number 59-AS-20241231154627
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: OAKWOOD MEADOWS ASSISTED LIVING
FACILITY NUMBER: 345920108
VISIT DATE: 01/03/2025
NARRATIVE
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9099C-1.. Allegation: Facility withheld residents medications upon move out. The allegation states the facility would not allow resident (R1) to take all of their medications or the medication orders to the new facility.

Both the Administrator and the Director of Nursing (DON) stated that prior resident (R1) did not have a diagnosis of Dementia but exhibited behaviors for the duration of the time they resided at the facility. Both managers confirmed that (R1) was taking several psychotic medications since moving in on/around end of June 2024, and the December MAR shows an effective date of 6/21/24 for these (3) medications.

LPA reviewed Physician's Orders, updated on 12/24/24, to note that Buspirone 10mg, Hydroxyzine HCL 50 mg tablets, and Trazadone 100mg were discontinued that day. The Medication Administration Record (MAR) for December 2024 reflects these (3) medications being discontinued effective 12/28/24 on the MAR, the day the facility entered the changes in the system. Charting notes state that (R1) was placed on alert charting for any adverse reactions or unusual responses to the (4) new supplements prescribed on 12/24/24- Fish Oil 1200MG, Preservision Areds, Probiotic Blend and D-Mannose 500MG.

Also discontinued were (9) other medications to be taken as needed for pain, constipation, cough, nausea and dry eye. The Director of Nursing stated the medication orders were updated by (R1's) regular primary care physician, whom they saw regularly. These (9) medications and all others that were not discontinued on 12/24/24, were discontinued effective 12/30/24, on the MAR, the day when (R1) moved from the facility.

Documentation was reviewed showing (24) medications were given to (R1) and their responsible person on 12/30/24, when moving from the facility. The Med-Tech staff confirmed that her signature and (R1's) family member's signature is listed on the documentation and that both (R1) and their family member were present when she returned (R1's) unused medications from the med cart and overflow, and there was no disagreement about the medications being returned. The MAR shows (21) medications were administered or scheduled to be administered through the evening of 12/30/24. (R1) moved out at approximately 5:00 pm. The discrepancy is due to (R1) having (2) bottles or bubble packs of fish oil and D-Mannose.

The DON confirmed that on 12/31/24, (1) additional medication, Lidocaine 5% was given to the facility nurse where (R1) moved to, as this medication was inadvertently not returned the day before at move out.

*cont on 9099C-2..
SUPERVISORS NAME: Maribeth Senty
LICENSING EVALUATOR NAME: Sabrina Calzada
LICENSING EVALUATOR SIGNATURE:

DATE: 01/03/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/03/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 59-AS-20241231154627
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: OAKWOOD MEADOWS ASSISTED LIVING
FACILITY NUMBER: 345920108
VISIT DATE: 01/03/2025
NARRATIVE
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9099C-2... The DON stated she indicated to the nurse that any medications that were not returned by 12/31/24 was due to the physician discontinuing them on 12/24/24, and the nurse stated she would follow up with contacting (R1's) doctor's office due to behaviors (R1) is showing at the new facility.

Based on information obtained, the facility followed the physician's orders and stopped giving all medication that was discontinued on 12/24/24 upon receiving the updated orders. The facility will ensure any discontinued medications will be destroyed promptly per facility protocols, and by (2) staff members.

Based on information obtained, LPA finds the allegation to be UNFOUNDED- A finding that the allegation is unfounded means that the allegation is false, could not have happened, and/or is without a reasonable basis.

Exit interview conducted. A copy of the report provided.
SUPERVISORS NAME: Maribeth Senty
LICENSING EVALUATOR NAME: Sabrina Calzada
LICENSING EVALUATOR SIGNATURE:

DATE: 01/03/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/03/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 3