345920108-2-18-2026-59-AS-MSEY-DRFSXL-20260219131608

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 345920108
Report Date: 02/18/2026
Date Signed: 02/18/2026 11:45:45 AM

Substantiated

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
11/13/2025 and conducted by Evaluator Sabrina Calzada

PUBLIC

COMPLAINT CONTROL NUMBER: 59-AS-20251113134057

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: 74	DATE:	02/18/2026
		UNANNOUNCED	TIME BEGAN:	11:00 AM
MET WITH:	Karen Padilla, Director of Nursing		TIME COMPLETED:	11:45 AM

ALLEGATION(S):

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Staff hit resident.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Sabrina Calzada arrived unannounced to deliver findings to a complaint received on November 13, 2025. LPA met with Director of Nursing (DON), Karen Padilla.

During the investigation, LPA interviewed the Administrator, the DON, and multiple faciity staff in Memory Care. LPA reviewed documentation relating to resident (R1), an incident report submitted for the incident occuring on September 1, 2025 and documentation from the faciltiy's internal investigation. The results of the investigation are as follows:

Resident (R1) moved to the Memory Care Unit in the facility, on May 30, 2025, with a primary diagnosis of Senile Dementia and a history of lung cancer. The LIC602 (10/30/2025) notes that (R1) has “Behavioral Expressions”, including disorientation, lack of hazard awareness and impulse control, expressions of frustrations and hallucinations.
**cont on 9099C-1..

Substantiated

Estimated Days of Completion:

SUPERVISORS NAME: Maribeth Senty
LICENSING EVALUATOR NAME: Sabrina Calzada
LICENSING EVALUATOR SIGNATURE:	DATE: 02/18/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/18/2026

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 59-AS-20251113134057

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: 02/18/2026

NARRATIVE

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9099C-1.. (R1’s) care plan (7/16/2025) states staff will ensure (R1) has safe ambulation, provide occasional assistance, they use a walker due to unsteady gait, and notes that (R1) "displays behavioral expressions such as agitation, refusal of care and confusion" and "requires reminders and cueing".

Allegation: Staff hit resident. The allegation states that staff, (S1), physically punched resident (R1), in the back of their head around the end of August or beginning of September, 2025, and then went after (R1) attempting to punch (R1) more, but another staff intervened so (S1) walked away.

LPA reviewed (5) staff statements and other documentation from the facility's internal investigation. (4) of the statements were from caregivers who were present at the start of the "am" shift on September 1, 2025, when the incident with (R1) occurred, and (1) statement was from the Med-Tech who received a verbal report from one of the caregivers later that same day, around 1:50 pm.

LPA interviewed each of these (5) staff and was provided with varying accounts of how the incident occurred from the (4) staff who were witnesses. Although all caregivers stated that they observed (R1) pulled (S1's) hair, one caregiver stated they heard (S1) call (R1) "crazy", just prior to (R1) pulling (S1's) hair. Another caregiver who is familiar with (R1) stated they have observed (R1) to become aggressive with other residents, but never with a staff.

Additionally, the written statements from the (4) caregivers do not include details or corroborate the information provided to the LPA during the interviews. One caregiver stated they provided details to management about what they witnessed; however, their written statement did not reflect a detailed account of the incident, and was not signed. LPA reviewed a second witness statement that also was not signed by the caregiver. The Med-Tech confirmed that what was reported to them by one caregiver was documented and submitted to management following the incident. In the Med-Tech's statement, it's also noted that (S1) was told they need to make a report of what was witnessed, as well as the (2) other caregivers who did not report what they witnessed.

The facility's internal investigation "determined that the resident abuse claim was inconclusive; however, concerns about professional conduct and proper intervention were substantiated". As part of a corrective action plan, (S1) was issued a Performance Improvement Plan (PIP) on September 6, 2025, requiring (S1) to complete "mandatory training in de-escalation techniques, dementia care and customer service standards" with the purpose to “provide corrective direction, training and support to ensure safe, professional and compassionate care practices”. *cont on 9099C-2..

SUPERVISORS NAME: Maribeth Senty
LICENSING EVALUATOR NAME: Sabrina Calzada
LICENSING EVALUATOR SIGNATURE:	DATE: 02/18/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/18/2026

LIC9099 (FAS) - (06/04)

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Control Number 59-AS-20251113134057

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: 02/18/2026

NARRATIVE

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9099C-2.. As part of the corrective action plan, (R1) was also required to review the facility's policies on Behavioral Intervention and Resident Rights, and participate in weekly 1:1 check-ins with a manager to discuss progress every (30) days. LPA reviewed documentation showing (R1) was evaluated on Oct 13, 2025, Dec 16, 2025, and on Jan 19, 2026.

The Ombudsman met with the Administrator and the DON initially on November 18, 2025 and was told an internal investigation was completed and there was no evidence found to substantiate the allegation of abuse. The Ombudsman returned to the facility on November 19, 2025 to inform facility managers that (S1) was involved in a similar incident, that was witnessed at an unrelated facility, on November 14, 2025. During the meeting on November 19, 2025, it was discussed that a Report of Suspected Dependent Adult/Elder Abuse (SOC341) should have submitted to the Long-Term Care Regional's Ombudsman's Office immediately following the reporting of the abuse. The facility submitted a completed incident report (LIC624) to the Department (CCLD) after this meeting.

Charting notes for (R1) show on 9/1/25 (1:00 am) staff made an entry that (R1) was observed with an indentation and cut on their outer right side of temple and that (R1) did not fall, but bumped their head on the night stand next to the bed, and refused to be sent out. Interviews concluded that staff were aware and observed (R1) had sustained bruising to their eye during the prior/NOC shift.

There were no notes entered by the Med-Tech for the altercation (R1) had with (S1) on 9/1/25 (around 6:15 am). The next notes were entered on 9/4/25 (1:52 pm) and 9/5/25 (1:16 pm) and state that resident’s eye bruises (black eye) are healing and going away, resident is not complaining of pain/discomfort, and staff will continue to monitor.

Based on information obtained, the allegation is found to be SUBSTANTIATED- A finding that the complaint is Substantiated means that the allegation is valid because the preponderance of the evidence standard has been met.

Per California Code of Regulations, Title 22, Division 6, Chapter 8, the following (2) citations are issued on the 9099-D page.
Exit interview. Copy of report and appeal rights provided.

SUPERVISORS NAME: Maribeth Senty
LICENSING EVALUATOR NAME: Sabrina Calzada
LICENSING EVALUATOR SIGNATURE:	DATE: 02/18/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/18/2026

LIC9099 (FAS) - (06/04)

Page: 2 of 4

Control Number 59-AS-20251113134057

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
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 02/18/2026

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 02/19/2026 Section Cited CCR 87468.1(a)(3)	1 2 3 4 5 6 7	87468.1 Personal Rights of Residents in All Facilities (a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (3) To be free from punishment, humiliation, intimidation, abuse, or other actions of a punitive nature, such as withholding residents’ money or interfering with daily living functions such as eating, sleeping, or elimination. This requirement is not met as evidenced by:	1 2 3 4 5 6 7	Licensee/Administrator immediately completed an inservice with all staff on mandated reporting. (R1) completed (6) classes of de-escalation and appropriately dealing with behaviors related to Dementia.
	8 9 10 11 12 13 14	Based on interviews conducted and documentation reviewed, the Licensee did not ensure that (R1) was not subjected to verbal and physical abuse by staff (S1), on September 1, 2025 (at approximately 6:15 am), which posed an immediate health and safety risk to residents in care.	8 9 10 11 12 13 14	The DON will advise by tomorrow, 2/19/26,what additional training will be conducted.
Type B 03/04/2026 Section Cited CCR 87211(a)(1)(D)	1 2 3 4 5 6 7	87211 Reporting Requirements (a) Each licensee shall furnish to the licensing agency such reports as the Department may require, including, but not limited to, the following: (1) A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence of any of the events specified in (A) through (D) below. This report shall include the resident's name, age, sex and date of admission; date and nature of event; attending physician's name, findings, and treatment, if any; and disposition of the case. (D) Any incident which threatens the welfare, safety or health of any resident, such as psychological abuse of a resident by staff or other residents, or unexplained absence of any resident. This requirement is not met as evidenced by:	1 2 3 4 5 6 7	Licensee/Administrator agree to read Regulation 87211 and submit a statement of understanding. Additionally, an In-Service training will be conducted with staff to review Abuse reporting requirements as stated on the SOC341A- Ombudsman training if possible.
	8 9 10 11 12 13 14	Based on interviews conducted and documentation reviewed, the Licensee did not ensure that the alleged incident reported to management, between (R1) and (S1) , on September 1, 2025, was timely reported to the Ombudsman's office and to CCLD,	8 9 10 11 12 13 14	The DON indicated (R1's) family was notified and didn't express any concerns.

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

SUPERVISORS NAME: Maribeth Senty
LICENSING EVALUATOR NAME: Sabrina Calzada
LICENSING EVALUATOR SIGNATURE:	DATE: 02/18/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/18/2026

LIC9099 (FAS) - (06/04)

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