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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 345920108
Report Date: 06/18/2025
Date Signed: 06/18/2025 05:05:29 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
05/07/2025 and conducted by Evaluator Sabrina Calzada
PUBLIC
COMPLAINT CONTROL NUMBER: 59-AS-20250507155152
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: DATE:
06/18/2025
UNANNOUNCEDTIME BEGAN:
01:45 PM
MET WITH:Karen Padilla, Director of Nursing TIME COMPLETED:
05:00 PM
ALLEGATION(S):
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Staff not treating resident with respect.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Sabrina Calzada arrived unannounced to deliver complaint findings to a complaint received on May 7, 2025, and met with Director of Nursing (DON), Karen Padilla, stating the reason for the inspection. LPA later met with the Administrator, Danny Torgersen,

During the course of the investigation, LPA interviewed the Administrator, the DON, the Resident Habilitation Director, Ombudsman, (2) representatives from a placement agency and resident (R1), who is the subject of the investigation. LPA reviewed documentation relating to (R1), including but not limited to, resident appraisal, physician's report, Care Conference case notes, other case notes and email communications with the Administrator. The results of the investigation are as follows:

Resident (R1) moved to the community on January 31, 2025 with the primary diagnoses of Psoriatic Arthritis, chronic low appetite and severe PTSD. (R1) was independent with Activities of Daily Living (ADL's), including medications, and was able to follow instructions, communicate needs and able to leave the facility alone. It's noted on the physician's report that (R1) could be depressed.
**cont on 9099C-1..

Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Maribeth Senty
LICENSING EVALUATOR NAME: Sabrina Calzada
LICENSING EVALUATOR SIGNATURE:

DATE: 06/18/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/18/2025
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 7
Control Number 59-AS-20250507155152
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: 06/18/2025
NARRATIVE
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9099C-1.. The Pre-Appraisal completed on January, 31, 2025, notes (R1) is ambulatory, is independent with transferring and toileting, needs stand-by assistance with bathing/dressing and medications, and needs daily monitoring due to behaviors.

Allegation: Staff not treating resident with respect. The allegation states (R1) feels like the Administrator “belittles” and “degrades” them, and does not respect them

The Care Conference notes, dated May 6, 2025, note that during the discussion, (R1) expressed that they “felt the Administrator was speaking negatively about them and asked if he had anything positive to say”. The notes say the Administrator replied that “it was not personal but that Oakwood Meadows now only accepts residents with RH services” and (R1’s) change in RH status makes them no longer eligible for their program”, and confirmed “RH is now a facility requirement and claimed (R1) was not receiving services consistently, which prompted disenrollment” from the program.

A social worker stated that the Administrator “can come off a bit harsh- the way he talks"; he “tried to be as respectful as possible, but it's his personality that he is a little intimidating and would address (R1) like "you have this problem" as if talking to a child.

The Ombudsman stated to LPA on May 19, 2025 that he "did not observe the Administrator to be condescending or rude to (R1) and (R1) could not provide an example when asked".

The Administrator stated via email on May 13, 2025 that (R1’s) “demands are extreme and constant though our responses to their demands are immediate and consistent”.

Based on information obtained, LPA finds this 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: 06/18/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/18/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 7
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
05/07/2025 and conducted by Evaluator Sabrina Calzada
PUBLIC
COMPLAINT CONTROL NUMBER: 59-AS-20250507155152

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: DATE:
06/18/2025
UNANNOUNCEDTIME BEGAN:
01:45 PM
MET WITH:Karen Padilla, Director of Nursing TIME COMPLETED:
05:00 PM
ALLEGATION(S):
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Unlawful eviction.
Staff not providing resident transportation to doctors appointments.
Staff retaliating against resident.
Staff does not provide a safe environment for resident.
INVESTIGATION FINDINGS:
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During the course of the investigation, LPA interviewed the Administrator, the DON, the Resident Habilitation Director, Ombudsman, (2) representatives from a placement agency and resident (R1), who is the subject of the investigation. LPA reviewed documentation relating to (R1), including but not limited to, resident appraisal, physician's report, Care Conference case notes, other case notes and email communications with the Administrator. The results of the investigation are as follows:

Allegation: Unlawful eviction. The allegation states that the Administrator initially stated (R1) could move out without providing a 30-day notice and followed up later when (R1) didn’t move out, asking (R1) if they were leaving the facility. When (R1) informed the Administrator, they did not find a place, the Administrator then told (R1) he had the impression that she was leaving and provided a 30-day notice to (R1).

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

DATE: 06/18/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/18/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 3 of 7
Control Number 59-AS-20250507155152
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: 06/18/2025
NARRATIVE
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9099A-C1. .. The Administrator stated via email, on May 13, 2025, that (R1) “has never been notified of, or reported to of the eviction process…There have never been notices sent to (R1) regarding eviction”… nor “have there been any discussion of (R1) being evicted”.

A Care Conference was held on May 6, 2025 with (R1), their social workers, Ombudsman and (3) facility managers. The Ombudsman asked for clarification at this meeting regarding the eviction (R1) feels she has received, and the Administrator stated (R1) had verbally given notice to the facility and mentioned moving out “multiple times over the past month”.

The notes state that (R1) commented that her “anxiety and PTSD sometimes lead her to say things she doesn’t mean, such as threats to move into the car”. According to the notes, the Ombudsman tried to explain to (R1) that their statements still “carry weight, and that the facility seems to be taking her at her word other than initiating eviction”. The notes state the Administrator confirmed that “no formal 30-day notice has been issued and agreed to allow (R1) to remain at the facility for another 30-days, emphasizing written move-out notice is requested from (R1)”, and the Administrator agreed (R1) could stay at the facility beyond 30-days if no alternative placement is found. The notes further state “The meeting concluded with mutual agreement that (R1) may remain at Oakwood Meadows while continuing to search for an alternative placement”.

The Care Conference notes document concerns made by the Administrator that (R1) has been frequently threatening to move out and live in their car. The Ombudsman added that (R1)’s “repeated verbal threats can be interpreted as notice and recommended that Oakwood Meadows notify licensing of such statements for documentation”. (R1) responded that their threats were made due to feelings of anxiety and frustrated and asked if they could be “retracted”.

(R1) confirmed with the LPA in May 2025 they had not received a written eviction notice since living at the facility.

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.



*cont on 9099A-C2..
SUPERVISORS NAME: Maribeth Senty
LICENSING EVALUATOR NAME: Sabrina Calzada
LICENSING EVALUATOR SIGNATURE:

DATE: 06/18/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/18/2025
LIC9099 (FAS) - (06/04)
Page: 4 of 7
Control Number 59-AS-20250507155152
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: 06/18/2025
NARRATIVE
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9099A-C-2.. Allegation: Staff not providing resident transportation to doctors appointments. The allegation stated staff (S1) was instructed by the Administrator to inform (R1) that she is no longer on the transportation service due to unenrollment from the RH program.

LPA was provided with a transportation schedule for Tuesday, May 6, 2025 showing (R1) received transportation that day, at 8:30 am, to a medical appointment. The Administrator explained via email on May 13, 2025, that the facility “has never denied this resident access to transportation” to any appointments, (R1) has a car and has driven it many times to their appointments… (R1) is allotted three transports, as needed, for medical related appointments per month”.. and resident must use their ”approved transports”.

The Administrator later emailed the LPA on May 19, 2025 that (R1) has “four transports per month that is covered on their insurance”, and “we attempt to use those transports first before we drive (R1) ourselves”. The email also states, in part, that (S1) “does not coordinate anything, just follows the schedule set for that day and is not responsible for making any appointments for (R1) or cancelling any appointments. When there is a conflict in scheduling, we will use our own transport van”.

LPA interviewed staff (S2) who is the Transportation coordinator. S2 stated she would assist (R1) in scheduling rides for medical appointments and (R1) never missed, or was late, to any of their scheduled appointments. (S2) stated she is not aware of a ride limit a resident can receive and explained that (R1) was also able to use their medical transport for non-emergencies, which she used before. Additionally, (S2) stated that the facility would have “emergency appointments” that would take priority and she did have to tell (R1) on one occasion that she needed to reschedule the appointment and gave (R1) one week to schedule one time. (S2) stated she would take direction from the Med-Tech and the Director of Nursing, who maintain the ride schedule, if a ride transport needed to be cancelled.

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.



*cont on 9099A-C3..
SUPERVISORS NAME: Maribeth Senty
LICENSING EVALUATOR NAME: Sabrina Calzada
LICENSING EVALUATOR SIGNATURE:

DATE: 06/18/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/18/2025
LIC9099 (FAS) - (06/04)
Page: 5 of 7
Control Number 59-AS-20250507155152
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: 06/18/2025
NARRATIVE
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*9099A-C-3.. Allegation: Staff retaliating against resident. The allegation states that the Administrator later told (R1) they have to be out of the facility within 30 days, after (R1) unenrolled from the RH Program.

(R1) stated they felt the program was not benefiting them and decided to un-enroll and after she un-enrolled from the program, (R1) started to have issues.

The Administrator stated in an email, sent on May 13, 2025, that “(R1) was originally enrolled in the RH Program when moving into the facility”; however, within the first month, (R1) rejected participation in the program, which offered them more time spent with specific assistants throughout the day. The email references other actions the facility has taken to “accommodate (R1’s) requests”, relating to their roommate situation and room assignment.

The Administrator communicated via email to the Department on May 13, 2025, that (R1) made multiple verbal threats to him, and many other staff, about moving out of the building and “verbally gave notice”. The email states that the facility has taken the “threats” seriously and are working with (R1’s) placement agency to find a facility that is better able to meet (R1’s) mental health needs.

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.




Allegation: Staff does not provide a safe environment for resident. The allegation states (R1) does not feel safe at the facility, due to interaction with staff.

LPA reviewed notes from May 6, 2025, when a care conference was held with (R1), their social workers, Ombudsman and (3) facility managers. The notes indicate that (R1) stated at the start of the meeting she felt “scared and threatened” by a prior meeting with (2) of the managers. The notes state that (R1) felt they were being pushed to move out of the facility due to no longer being enrolled in a particular program that some of the residents are enrolled in.

*cont on 9099A-C-4..

SUPERVISORS NAME: Maribeth Senty
LICENSING EVALUATOR NAME: Sabrina Calzada
LICENSING EVALUATOR SIGNATURE:

DATE: 06/18/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/18/2025
LIC9099 (FAS) - (06/04)
Page: 7 of 7
Control Number 59-AS-20250507155152
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: 06/18/2025
NARRATIVE
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*9099A-C-4.. The Administrator emailed the Department on May 13, 2025 that the facility has taken many steps to accommodate (R1) and their requests, including changing roommates and room assignments, and making personnel changes.

The email states the facility has never received a complaint that a resident is unsafe and (R1) has voiced concerns of “feeling unsafe when hearing sounds, temperatures, night-lights, television noises” and other noises such as voices.

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. Copy of report provided.
SUPERVISORS NAME: Maribeth Senty
LICENSING EVALUATOR NAME: Sabrina Calzada
LICENSING EVALUATOR SIGNATURE:

DATE: 06/18/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/18/2025
LIC9099 (FAS) - (06/04)
Page: 6 of 7