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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 345920108
Report Date: 04/10/2025
Date Signed: 04/10/2025 04:24:56 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
01/08/2025 and conducted by Evaluator Sabrina Calzada
PUBLIC
COMPLAINT CONTROL NUMBER: 59-AS-20250108113928
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: 75DATE:
04/10/2025
UNANNOUNCEDTIME BEGAN:
10:40 AM
MET WITH:Director of Nursing, Karen Padilla and Kayla Peria, Director of Care and AdmissionsTIME COMPLETED:
01:00 PM
ALLEGATION(S):
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Staff did not safeguard resident's possessions while in care.
Staff did not ensure that resident's laundry needs were met while in care.
Staff did not accord dignity to resident while in care.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Sabrina Calzada arrived unannounced to continue the complaint investigation and deliver partial findings to a complaint received on January 8, 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 and reviewed pertinent documentation related to resident (R1) including physician's report, charting notes, incident report and other documentation. The results of the investigation are as follows:

Resident (R1) moved to the community on June 28, 2024 and moved out December 30, 2024. (R1's) physician's report (October 31, 2024) notes they have multiple diagnoses, including Parkinson's Disease, does not have Mild Cognitive Impairment (MCI) or Dementia, is able to leave the facility unsupervised, and can determine and communicate their need for prescription/non-prescription medication.
*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 4
Control Number 59-AS-20250108113928
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.. Allegation: Staff did not safeguard resident's possessions while in care. The allegation states staff did not return clean laundry as (R1) would not get many of their items back. Sheets, certain clothing, slippers and phone charger went missing, and were never returned to (R1) upon move out.

LPA spoke to the laundry staff in Assisted Living who indicated she did not work at the community when (R1) resided here. The staff explained the laundry processes and that each resident has a laundry bag to collect clothing that needs laundry, laundry is completed at least weekly for each resident, and returned the same day. This staff stated there has not been a "Lost and Found" bin since she started in February 2025 and in general, residents are very happy with the laundry service.

LPA spoke to a care staff who stated (R1) "would take other residents' items, including from her roommates" and she found their photos in (R1's) closet one time and asked (R1) to return the items". This staff stated (R1's) phone was not missing as they were on their phone all the time and carried it around". This staff stated that none of her items, such as slippers or clothing, went missing and (R1) was given wipes and pull-ups the last four weeks too before they left". This staff further explained that (R1) was a tall person and their clothes, pants, would not have fit the staff at the community. The Administrator stated there is "no record of (R1) having a black iPhone or that it was reported missing" and that (R1) was "in his office all of the time" also.

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.

Allegation: Staff did not ensure that resident's laundry needs were met while in care. The allegation states staff rarely took (R1's) laundry to have it cleaned.

A laundry staff explained that each resident has a laundry bag to collect items needing laundering, and laundry is completed weekly for each resident. This staff stated residents are generally very happy with the laundry service but did not work at the community when (R1) lived here. A care staff stated (R1)"wanted her laundry done" and so I would talk to them about that, adding "I went out of my way to do laundry for (R1)-I did theirs privately every day or other day- I would personally wash it and return it to them" and confirmed "staff labels all resident's clothing", explaining "We have a separate laundry lady who labels all resident clothes". Based on information obtained, LPA finds the allegation to be UNSUBSTANTIATED.
*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)
Page: 2 of 4
Control Number 59-AS-20250108113928
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.. Allegation: Staff did not accord dignity to resident while in care. The allegation states that (R1) was treated horribly by staff while living at this facility.

A main care staff confirmed she recalls prior resident, (R1) and she did not have any problems working with them however, (R1) "didn't like everyone and was aggressive and verbally mean to staff and residents". This staff further explained "every staff was always nice to (R1), commenting "we train the girls for kindness".

A manager stated (R1) was friendly with staff and residents initially but then would turn on them and accuse of them of stealing or lying. LPA spoke to (2) prior roommates who said (R1) was verbally threatening and mean to them.

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. Copy of 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)
Page: 3 of 4