345920108-4-11-2025-59-AS-MSEY-DFRLZD-20250415091145

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 345920108
Report Date: 04/11/2025
Date Signed: 04/11/2025 02:04:41 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 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:	04/11/2025
		UNANNOUNCED	TIME BEGAN:	10:50 AM
MET WITH:	Danny Torgersen, Administrator		TIME COMPLETED:	02:00 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Licensee did not ensure that resident was administered their medications according to physician's instructions while in care.
Licensee does not ensure that residents are provided with food that is of good quality while in care.
Staff did not respond to resident's requests for assistance as necessary while resident was in care.

INVESTIGATION FINDINGS:

1
2
3
4
5
6
7
8
9
10
11
12
13

Licensing Program Analyst (LPA) Sabrina Calzada arrived unannounced to deliver findings to the remaining (3) allegations for a complaint received on January 8, 2025. LPA met with Administrator, Danny Torgersen, and stated the reason for today's inspection. LPA met with Director of Nursing, Karen Padilla, later during the inspection.

During the investigation, LPA interviewed multiple staff and several residents and reviewed documentation related to resident (R1), who is the subject of the investigation. Documentation included (R1's) physician's report, charting notes, physician's orders and the Medication Administration Record (MAR) for December 2024. The results of the investigation are as follows:

(R1) moved in on/around June 28, 2024 and resided in the Assisted Living Unit. The physician's report (October 31, 2024) notes (R1) has multiple diagnoses, but 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: 04/11/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/11/2025

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 5

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: 04/11/2025

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

9099C-1.. Allegation: Licensee did not ensure that resident was administered their medications according to physician's instructions while in care. The allegation states the facility discontinued (R1’s) medications so (R1) was not provided the medications they needed, including Hydroxyzine, Buspirone, Trazadone, Eye Drops for macular degeneration, and other anti-anxiety medications, which caused (R1) to suffer for a long time while living at the facility.

NOTE: The Department investigated a related allegation (Facility withheld resident’s medications upon move out) in January 2025, and those findings were determined to be Unfounded.

Physician's orders, dated August 15, 2024, note (R1) had (18) scheduled medications, including: Trazodone 100mg and Hydroxyzine HCL 50mg, and (13) PRN medications including Buspirone 10 mg and Propyl Glycol/Peg/.3/.4% UD (for dry eyes). There is not a prescription for any other eye drops.

Physician's orders, dated December 24, 2024, list (22) scheduled medications and (12) PRN medications. Also noted on this documentation are several discontinuance orders, including for (3) psychotic medications, 24including for Buspirone 10mg tablet, Hydroxyzine HCL 50 mg tabs, Trazadone 100mg and several PRN medications, including the Propyl Glycol/Peg/.3/.4% UD. There is not a prescription for another eye drops.

The MAR for December 2024 shows that Buspirone 10 mg was administered, twice daily, as ordered, and Trazadone 100mg tab was administered daily, as ordered, at bedtime, through December 28, 20. The MAR also shows Hydroxyzine HCL 50mg, was administered three times daily, as ordered, except for 5:00 pm dosage on December 7 and 26, through December 28, 2024, also. There are no notations indicating why this medication was not administered at these two times. Additionally, the MAR also shows medications Gabapentin 300mg, Buspirone 10mg, and Prazosin HCL1 mg have missing initials on the same days/times, suggesting a staff error.

The MAR shows PRN Propyl Glycol/Peg/.3/.4% UD, was not issued during the month of December 2024 and notes all other medications were administered, as ordered. There are no additional eye drops listed on the MAR that they were administered.

*cont on 9099C-2..

SUPERVISORS NAME: Maribeth Senty
LICENSING EVALUATOR NAME: Sabrina Calzada
LICENSING EVALUATOR SIGNATURE:	DATE: 04/11/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/11/2025

LIC9099 (FAS) - (06/04)

Page: 2 of 5

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: 04/11/2025

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

9099C-2.. (R1's) charting notes do not have any entries for December 7 and 26, related to medications and only that (R1) was showing behaviors on the morning of December 26, 2024.

Charting Notes from 12/27/24 document that (R1) asked for Hydrocxazine, and when staff told (R1) it’s a scheduled not PRN, (R1) began cussing at staff/calling them derogatory names and accusing the facility of lying and stealing their medications. Charting notes from 12/30/24 show (R1)was placed on alert charting for “new supplements” and was prescribed “new medications, commencing on 12/30/24 0800 hours: fish oil 1200 MG, Preservision A-reds, Probiotic Blend, D-Mannose 500 MG.

LPA spoke with a Med-Tech staff who was familiar with (R1)'s medications and stated (R1) took mostly supplements, including an eye vitamin, and did not recall (R1) taking any eye drops. This staff indicated that (R1) was very particular about the medications they took, was aware of each one, and would regularly question staff about it.

One of (R1's) prior roommates stated to LPA that "(R1)had problems with medications daily and would count them and then argue with staff everyday" that (R1) wasn't given the correct meds.

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: Licensee does not ensure that residents are provided with food that is of good quality while in care. The allegation states when (R1) lived at the facility, the food was terrible and barely edible and (R1) often had to spit it out. It's also alleged that the food is served cold.

The Culinary manager stated he does not recall (R1) living at the community and was out of the facility during the month of November 2024. The manager explained in January 2025 that the facility's main convection oven has always worked, and the prior "steam table" had a small leak, but it has been replaced. On January 17, 2025, LPA observed the food warmer to show a temperature of 148*F and plates are being placed there to be warmed before serving food on them.

*cont on 9099C-3..

SUPERVISORS NAME: Maribeth Senty
LICENSING EVALUATOR NAME: Sabrina Calzada
LICENSING EVALUATOR SIGNATURE:	DATE: 04/11/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/11/2025

LIC9099 (FAS) - (06/04)

Page: 3 of 5

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: 04/11/2025

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

9099C-3..The manager explained that staff will "take temperatures of all food at every meal" and ensure the temperatures are "per normal cooking temperatures". The manager added that during November 2024, there were "no issues with the food temperatures, per the paperwork that was completed", asserting "the food is never served cold, except for sandwiches and salads".

A caregiver staff who assisted (R1) indicated that (R1) "never complained about the food and would ask for sandwiches, salad, fruit and the culinary manager would make it" and (R1) "ate all of the food and she never observed (R1) to complain about it". During the interview, this caregiver staff brought a warm plate to LPA from the kitchen where LPA was able to confirm the plate was "warm-hot" to the touch.

The Department received additional information in February 2025, relating to another resident (R2). The report stated that this kitchen does not know what resident likes or dislikes. LPA discussed this resident with the culinary manager who indicated he has been meeting weekly with (R2) to provide a monthly menu and discuss alternative options, if needed, to the menu items. LPA met with (R2) on April 10, 2025 to discuss their concerns. (R2) showed LPA a copy of the April menu and notations they made where they don't like the food preferences. (R2) stated the kitchen staff are "trying" and it's better but (R2) "still struggles to get food they likes- stating they eat a lot of yogurt, cottage cheese to get protein. Additionally, (R2) expressed the facility doesn't offer an evening snack, which is needed since dinner is served early around 4:30-5:00 pm, and agreed that Protein Drinks (ie. Ensure) would be great to have available in between meals.
(R2) stated lasagna, spaghetti, enchiladas, and quiche with spinach, are favorite foods served and the when they started doing "dinner salads". grilled cheese or another sandwich have been the only alternatives to the main menu entree, until recently with "dinner salads" offered.

LPA spoke to (1) additional resident on April 11,2025, who indicated they do not like most of the food, due to the taste or type of food, and grilled cheese sandwiches are their first choice of a meal. The weekly menu is posted outside the main dining area and all meals appear to be balanced with a main entree, vegetable or fruit side, beverage and dessert.

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.
*cont on 9099C-4.

SUPERVISORS NAME: Maribeth Senty
LICENSING EVALUATOR NAME: Sabrina Calzada
LICENSING EVALUATOR SIGNATURE:	DATE: 04/11/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/11/2025

LIC9099 (FAS) - (06/04)

Page: 4 of 5

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: 04/11/2025

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

9099C-4..Allegation: Staff did not respond to resident's requests for assistance as necessary while resident was in care. The allegation states staff would not respond when (R1) would pull their cord to request assistance and (R1) "could have died" because of staff ignoring the requests for assistance.

A care staff who provided care to (R1) was asked if staff answer (R1's) calls promptly. This staff stated "Yes, we always answer- there is a dispatcher here seven days per week and the lead maintenance staff tests the buttons weekly. This staff commented, "I treated (R1) like a VIP and staff was extra nice to (R1)".
Interviews conducted revealed that (R1) had multiple roommates and was initially friendly to people but later became upset and accusatory towards many.

LPA spoke to (R2) about concerns brought to the Department's attention in February 2025. (R2) stated that most of the time staff respond promptly, within (30) minutes on the "am" and "pm" shifts, but staff often do not respond timely during the night time hours. (R2) offered an explanation that "NOC is really bad because there is no one at the reception desk during graveyard to monitor the calls". (R2) added they don't think NOC staff are sleeping, but that there just aren't enough staff" at this time, stating "2 staff is "not enough", to cover Memory Care also. The Administrator and Director of Nursing confirmed there are (5) total staff on overnight shift and staff will cover where needed in either unit.

(R2) was asked about additional concerns brought to the department's attention. (R2) stated they feel staff do not provide as complete incontinent care as possible, including using wipes with a urine soiled diaper, due to being "rushed" and having to get to the next resident. (R2) confirmed they will hear staff's radio announce another resident needs assistance, so staff have to go. LPA and (R2) discussed one additional issue related to incontinent care. (R2) explained that (R2) was providing their own wipes but ran out of briefs and liners last Sunday, April 8, explaining additional incontinent supplies are kept upstairs in the supply room and there is one staff who has a key and she was off work on the weekends. (R2) stated last Sunday was the first time it was "that bad" and staff had to really look for supplies. The Administrator and Director of Nursing stated the supply room door has a combination lock and not a key lock and at least (1) staff on every shift is able to access any needed supplies,and there is not insufficient staffing during the night time hours.

The facility stated reports for pendant call response times are not available after (30) days and (R1) moved out on December 30, 2024.
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: 04/11/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/11/2025

LIC9099 (FAS) - (06/04)

Page: 5 of 5