345920108-4-10-2025-59-AS-MSEY-DFRLZR-20250415091222

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 345920108
Report Date: 04/10/2025
Date Signed: 04/10/2025 04:22:55 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
01/23/2025 and conducted by Evaluator Sabrina Calzada

PUBLIC

COMPLAINT CONTROL NUMBER: 59-AS-20250123091955

FACILITY NAME:	OAKWOOD MEADOWS ASSISTED LIVING		FACILITY NUMBER:	345920108
ADMINISTRATOR:	TORGERSEN, DANIEL		FACILITY TYPE:	740
ADDRESS:	7241 CANELO HILLS DR		TELEPHONE:	(916) 722-2800
CITY:	CITUS HEIGHTS	STATE: CA	ZIP CODE:	95610
CAPACITY:	78	CENSUS: 75	DATE:	04/10/2025
		UNANNOUNCED	TIME BEGAN:	01:40 PM
MET WITH:	Director of Nursing, Karen Padilla and Kayla Peria, Director of Care and Admissions		TIME COMPLETED:	04:30 PM

ALLEGATION(S):

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Due to lack of supervision, resident was assaulted.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Sabrina Calzada arrived unannounced to complete the complaint investigation and deliver findings for a complaint received on January 23, 2025. LPA met with Kayla Peria, Director of Care and Admissions, and stated the reason for the inspection. Director of Nursing, Karen Padilla, met with LPA at 12:15 pm.

During the investigation, LPA interviewed multiple staff and several residents. Documentation was also reviewed, including, incident reports submitted to the Department, and pertinent paperwork from resident (R1/R2/R3's) files. The results of the investigation are as follows:

The alleagation states that resident (R1) was assaulted several times in the last (4) months, (R1) is independent, and the Administrator refuses to let (R1) leave the building. There were no specific details on when the alleged assaults occurred.

*Cont on 9099C-1..

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Maribeth Senty
LICENSING EVALUATOR NAME: Sabrina Calzada
LICENSING EVALUATOR SIGNATURE:	DATE: 04/10/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/10/2025

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-20250123091955

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: 04/10/2025

NARRATIVE

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9099C-1. Resident (R1) moved to the facility on/around September 4, 2024 with a primary diagnosis of Epilepsy due to seizure activity, and a secondary diagnosis of Hypothyroidism and Mild Cognitive Impairment. The Physician's report dated August 30, 2024, notes (R1) can be confused at times, does not show inappropriate behavior, is able to follow instructions and communicate needs and can be depressed. The care plan notes (R1) is in "overall good health", is independent and ambulatory and needs supervision and cueing with bathing and assistance with medications.

(R1) stated to LPA end of January 2025 that they are "independent" and want to move from the facility and live on their own. (R1) stated their prior roommate (R2) "pummelled them and hit them over and over" on/around November 12, 2024, the Director of Care and Admissions pulled (R2) off of (R1), and they informed the managers and Ombudsman following the incident. (R1) stated (R2) assaulted them due to them turning off the heater in the room. (R1) stated they went to the hospital, a police report was filed, and they returned to the community in the morning on November 12, 2024. (R1) added that (R2) "verbally assaulted them on November 13, 2024 and then tried to physically assault them again on November 14, 2024, both for "no real reason".

(R1) stated to LPA on the same day that resident (R3) attacked them in the dining room on October 31, 2024, during a Halloween party, and later again, at the puzzle table in the common area. (R1) stated these incidents were immediately reported to facility management. Charting notes for (R1) shows (R1) regularly refused scheduled medications since moving in and told staff the doctor discontinued them.

The Department received an incident report for an incident occurring on November 11, 2024 (6:00 pm) where (R1) called 9-1-1 to report their roommate (R2) and another resident (R3) was stalking them, and (R1) told the police they wanted to move out. The incident report and hospital discharge paperwork note (R1) returned at 10:30 am on November 12, 2024. Hospital paperwork notes (R1) was diagnosed with Urticaria (hives). The incident report states there were no new orders given at the hospital, resident has been refusing medications at the community.

The facility submitted a prior incident report for an incident on November 6, 2024 when (R1) called 9-1-1 stating they were having a heart attack. (R1) was taken to the hospital, had labs and various tests done that returned with results within normal range. Returned returned the next day with no new orders.

(cont on 9099C-2..)

SUPERVISORS NAME: Maribeth Senty
LICENSING EVALUATOR NAME: Sabrina Calzada
LICENSING EVALUATOR SIGNATURE:	DATE: 04/10/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/10/2025

LIC9099 (FAS) - (06/04)

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Control Number 59-AS-20250123091955

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: 04/10/2025

NARRATIVE

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9099C-2.. LPA spoke to resident (R4), also a prior resident of (R2), who stated they never witnessed (R2) physically attacking another resident, but (R2) told them one time they "threw a cup of water in another roommate's face because they didn't like the roommate snoring". (R4) stated (R2) verbally threatened them one time, and they were moved to another room. LPA interviewed resident (R3) in March 2025. (R3) indicated they are one of a few residents who like to walk in the building and (R1) is another resident who does also. (R3) stated they have only talked to (R1) as (R1) is "nice" and they have never followed them or physically attacked them. (R3) showed LPA the number of steps they take each day as they walk throughout the building on their cell phone.

One staff stated to LPA in March they were told from other staff they witnessed (R2) hit (R1) and harass them, but this staff was not at work that day. This staff stated (R2) "threatened resident (R5) who is currently at the hospital, along with her roommates, (R1) and (R6) and threw water on them". Multiple other staff stated they only heard "verbal exchanges" between (R1) and (R2) while they were roommates for (12) days.

Multiple staff interviews with managers confirmed that (R3) keeps to themself while walking, participates in activities and has never been observed to attack or physically touch any resident. Charting notes for (R3) note that they pushed and kicked resident (R7) on November 12, 2024 and tried hitting resident (R8) on December 14, 2024. The Activity Director stated (R1) is "pretty independent" and likes to exercise and do laps around the building, and she has never noticed (R1) to have any issues with (R3) as (R1) spends a lot of time in their room. This Director stated (R3) is very helpful and has never been observed to physically try to touch any resident. Both the Activity Director and Maintenance Director stated they have "never seen (R1) and (R3) interact".

The Care and Admissions Directed stated that the internal investigation was completed and at the time, (R1) and(R2) were both interviewed, there were "no bruises or scratches" observed, commenting they "argued a lot over the volume of the television, and (R1) said (R2) was going through (R1's) stuff. (R1's) family member stated there was never any evidence that (R1) had any bruising or injuries from the alleged attacks.

Based on information obtained, LPA finds the allegation to be 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: Sabrina Calzada
LICENSING EVALUATOR SIGNATURE:	DATE: 04/10/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/10/2025

LIC9099 (FAS) - (06/04)

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