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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 345920108
Report Date: 02/04/2025
Date Signed: 02/04/2025 11:58:04 AM

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
12/02/2024 and conducted by Evaluator Kevin Mknelly
PUBLIC
COMPLAINT CONTROL NUMBER: 59-AS-20241202113451
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: 69DATE:
02/04/2025
UNANNOUNCEDTIME BEGAN:
11:10 AM
MET WITH: Daniel TorgersonTIME COMPLETED:
12:00 PM
ALLEGATION(S):
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Due to staff neglect, resident received multiple pressure injuries
INVESTIGATION FINDINGS:
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On 2/4/25, Licensing Program Analyst (LPA) Kevin Mknelly conducted an unannounced complaint investigation visit to deliver the findings for the above allegations and met with Daniel Torgerson.

LPA conducted facility and home health records review and extensive interviews.
LPA is unable to find and or meet the preponderance, per policy.

R1 was admitted on 9/12/24 with history of CVA, heart failure and dysphagia. At admission, R1 also had redness on their heal and coccyx. Home Health was provided throughout R1's stay. 10/3/24, R1 had a new stroke which contributed to further decline.
Throughout R1's stay, records and interviews found that R1's care plan was followed as directed by home health and resident appraisals.
R1 was sent to the hospital on 12/2/24 for change of condition and passed away in the hospital on 12/4/24.
report continued...
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Maribeth Senty
LICENSING EVALUATOR NAME: Kevin Mknelly
LICENSING EVALUATOR SIGNATURE:

DATE: 02/04/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/04/2025
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 2
Control Number 59-AS-20241202113451
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: 02/04/2025
NARRATIVE
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Records reviews and interviews found no additional evidence to support that R1's pre-existing conditions were made worse due to neglect.

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 and report provided.
SUPERVISORS NAME: Maribeth Senty
LICENSING EVALUATOR NAME: Kevin Mknelly
LICENSING EVALUATOR SIGNATURE:

DATE: 02/04/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/04/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 2