Complaint·August 26, 2025

Interviews conducted with staff members S1, S2, S3, and S4, along with residents R2, R3, R4, R5, R6, R7, R8, R9, R10, and R11 indicated that they had no concerns regarding personal rights violations at the facility. Facility staff are not providing incontinence care to residents in need Interviews conducted with staff members S1, S2, S3, and S4, along with residents R2, R3, R4, R5, R6, R7, R8, R9, R10, and R11 indicated that they had no concerns regarding staff providing incontinence care to residents in need. Physician’s Report (LIC 602A) for resident (R1) dated November 19, 2024 indicates that R1 is not confused/disoriented, is able to follow instructions, and is able to communicate their own needs. LIC 602A for R1 states that R1 has bladder and bowel impairment, but R1 is able to care for their own toileting needs. Level of Care Appraisal for R1 dated December 11, 2024 indicates that R1 requires verbal reminders for toileting. Service Plan for R1 indicates that R1 received "verbal reminder for toileting" every day. LPA reviewed Progress Notes for R1 and did not observe any concerns regarding incontinence care. Facility staff are not ensuring facility is clean and in good repair Interviews conducted with staff members S1, S2, S3, and S4, along with residents R2, R3, R4, R5, R6, R7, R8, R9, and R10 indicated that they had no concerns regarding facility being unclean or in disrepair. During visit conducted on May 15, 2025, LPA observed R1’s apartment and observed apartment to be clean and in good repair. LPA observed resident apartments on August 5, 2025 and August 19, 2025, and observed resident apartments to be clean and in good repair. During visits conducted on May 15, 2025, July 8, 2025, August 5, 2025, August 15, 2025, August 19, 2025, and August 26, 2025, LPA observed premises to be clean and in good repair. ** Report continued on 9099-C ** Facility is not addressing resident sustaining falls Interviews conducted with staff members S1, S2, S3, and S4, along with residents R2, R3, R4, R5, R6, R7, R8, R9, R10, and R11 indicated that they had no concerns regarding staff providing assistance with residents sustaining falls. LPA reviewed Progress Notes for R1 and observed the following regarding falls for R1: January 4, 2025: R1 “slipped from chair to ground, … [R1] says [they] didn’t hurt [themselves] and no pain at the moment.” January 5, 2025: R1 “has no complaints of pain or discomfort.” There were no other documentation at the facility indicating any other incidents regarding falls for R1. Based on interviews conducted, observations, and records reviewed, the preponderance of evidence standards have not been met. Therefore, the above allegations are found to be UNSUBSTANTIATED. A finding that a complaint allegation 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 was conducted. A copy of this report was provided. Signature on these forms acknowledges receipt of these documents. LPA obtained and reviewed eviction notice issued to resident (R1). LPA observed notice to be lawful in accordance with Health and Safety Code regulations pertaining to eviction notices for Residential Care Facilities for the Elderly (RCFEs). Reason for eviction notice was for failure “to comply with the general policies of The Terraces of Roseville.” Policy violation included “on April 16, drug paraphernalia was found within the resident’s belongings.” LPA reviewed R1’s admission agreement, which states “residents must not bring any illegal substance (e.g., illegal drugs) into their Apartments or anywhere on the premises of THE TERRACES OF ROSEVILLE and must ensure that their family members, guardians, personal representatives and guests abide by this policy.” LPA reviewed a hospital After Visit Summary for R1 dated April 16, 2025 which states R1’s diagnosis was “Methamphetamine use.” Physician’s Report (LIC 602A) for R1 states that R1 is able to leave the facility unassisted. Interview with staff member (S4) indicated that, on April 16, 2025, the front desk called that R1 needed assistance. S4 stated that they announced themselves before entering R1’s apartment. S4 stated that R1 was not wearing pants and was going to get dressed. S4 stated that they went to obtain pants for R1 and, when they opened the drawer, a pipe rolled right out of the pants. S4 stated that they shut the drawer and called ED. ED came in to talk to R1 and sent R1 to the hospital. LPA reviewed Progress Notes for R1 and observed the following instances documented regarding R1’s drug use: December 5, 2024: R1 was observed leaving the facility with their friend in their apartment “possibly smoking weed” as there was an odor in the hallway outside of apartment and odor came directly from R1’s apartment upon entry. R1 was observed smoking weed with friend. December 6, 2024: R1 was observed smoking weed in apartment “along with other drugs.” Indicates R1 has been sneaking friend in apartment and “does drugs.” A “cloud of smoke” was observed coming from R1’s apartment with an “even stronger smell of weed.” ** Report continued on 9099-C ** December 11, 2024: R1 admitted at hospital and tested “positive for methamphetamine and marijuana.” December 15, 2024: “A strong chemical smell” was observed coming from R1’s apartment. “Resident and guest [were] acting weird.” December 16, 2024: R1 “was on something clearly” and was “speaking like another language (gibberish).” Staff noted “who knows what other drugs [R1] is mixing” with prescribed medications. Staff observed R1’s authorized representative on site to be upset with R1’s “recent drug use.” December 26, 2024: Care staff visited R1 and expressed “concern over [R1] testing positive for meth.” Care staff “explained that drugs are not allowed in the community” with R1. December 29, 2024: R1 and friend were observed “smoking weed” with odor in hallway outside apartment. January 11, 2025: R1 and friend were observed “smoking weed” with odor in hallway outside apartment. April 16, 2025: R1 was observed being “extremely high” and R1 told staff they were high. “Staff came to ED office to report finding a ‘meth’ pipe in the residents drawer while assisting resident with dressing. Staff member stated they grabbed a pair of sweats out of the drawer and when they picked them up the pipe was there. They put the pants back over the pipe and came to report. ED went back up with staff and knocked and entered apartment. They showed [ED] the drawer and ED picked up the pipe. ED asked [R1], ‘what is this?’ [R1] stated it was [friend’s]. ED asked if resident also did meth with [friend] and [R1] said, ‘yes [R1] did.’” Facility recommended R1 be transported to hospital and R1 was taken to ER. May 5, 2025: Odor of weed was observed “emanating” from R1’s apartment. Unusual Incident/Injury Report dated April 22, 2025 indicates that, on April 16, 2025, R1 reported to med tech that they were “high” and staff observed drug paraphernalia in apartment. R1 was transported to the hospital and paraphernalia was removed. R1 tested positive for methamphetamine and was medically cleared for discharge. R1 reported to hospital that they were agreeable to entering a rehabilitation program. ** Report continued on 9099-C ** Based on interviews conducted and records reviewed, the above allegation is found 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 was conducted. A copy of this report was provided. Signature on these forms acknowledges receipt of these documents.