Inspection Reports for The Terraces of Roseville

The inspection was an unannounced complaint investigation visit triggered by multiple allegations including violations of residents' personal rights, failure to provide incontinence care, failure to maintain facility cleanliness and repair, failure to address resident falls, and issuance of an unlawful eviction notice.

All allegations related to personal rights violations, incontinence care, facility cleanliness, and fall assistance were found to be unsubstantiated based on interviews, observations, and record reviews. The allegation regarding an unlawful eviction notice was found to be unfounded as the eviction notice was lawful and supported by documented resident drug use incidents.

The complaint investigation was initiated based on allegations received on 2025-05-12. The investigation included interviews with staff and residents, review of documentation, and observations. The allegations of personal rights violations, inadequate incontinence care, poor facility maintenance, and failure to address falls were unsubstantiated. The allegation of unlawful eviction was unfounded, with evidence showing the eviction was due to resident drug use and was in compliance with regulations.

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The inspection was an unannounced Required-1 Year Inspection conducted to ensure compliance with Title 22 regulations for the care home.

The inspection found the facility to be in compliance with all applicable regulations, with properly furnished resident apartments, sanitary bathrooms, safe food storage, operational safety equipment, and locked medication storage. No deficiencies were cited during this visit.

The inspection was an unannounced complaint investigation triggered by allegations that staff were mismanaging residents' medications and that staff did not meet the qualifications to administer residents' medications.

The investigation substantiated the allegations that staff mismanaged medications, including a medication error where a resident ingested another resident's medications, and that one staff member did not complete required annual medication training for multiple years. Deficiencies were cited and a civil penalty of $250 was assessed for a repeat violation.

The complaint was substantiated. Allegations included staff mismanaging residents' medications and staff not meeting qualifications to administer medications. The investigation included review of medication error reports, medication counts, training documentation, and interviews. A civil penalty was assessed for a repeat violation.

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The visit was a case management health and safety check conducted by the Licensing Program Analyst following receipt of a death report for a resident.

No deficiencies were cited as a result of this unannounced case management health and safety check visit.

The visit was an unannounced case management visit to confirm orders for immediate exclusion of an individual from all facilities.

The facility was informed of an immediate exclusion effective May 14, 2025, requiring removal of the individual S1 from any contact with clients and prohibiting physical presence in the facility.

An unannounced complaint investigation was conducted due to allegations that staff mismanaged residents' medication and did not report the incident.

The investigation substantiated the allegation that staff mismanaged residents' medication, finding that a resident did not receive medications as prescribed, posing an immediate health and safety risk. A deficiency was cited. Another allegation that staff did not report the incident was found to be unfounded.

The complaint investigation was substantiated regarding medication mismanagement based on an incident where morning medications were found not taken in a resident's apartment. The facility conducted staff training following the incident. The allegation that staff did not report the incident was found to be unfounded.

The visit was a case management follow-up regarding a potential fire on site triggered by smoke from a microwave incident involving a resident.

No fire was found on the premises, no damage was observed in the resident's apartment, and no deficiencies were cited during the visit.

The visit was conducted to issue a civil penalty related to a previous inspection conducted on 2024-08-21 for a violation involving the absence of supervision.

An immediate civil penalty of $500 was assessed for the violation of absence of supervision found during the inspection on 2024-08-21. The penalty was issued during the visit on 2024-10-23.

The inspection was a Required-1 Year unannounced visit conducted to ensure compliance with Title 22 regulations for the assisted living facility.

The inspection found the facility to be in compliance with all applicable regulations, with no deficiencies cited. Apartments and common areas were properly maintained, medication storage was secure, and safety equipment was operational.

The inspection was an unannounced complaint investigation visit triggered by an allegation that staff did not prevent a resident from eloping.

The investigation found that the facility failed to properly supervise resident R1, who eloped from the facility and was found by police in a nearby field. The facility also delayed reporting the resident missing to 9-1-1, posing an immediate health, safety, and personal rights risk. The allegation was substantiated.

The complaint was substantiated. The allegation was that staff did not prevent a resident from eloping. The resident was missing from approximately 6:00 PM until located by police at 8:00 PM. Staff delayed reporting the resident missing to 9-1-1, and the resident was found stuck in tall brambles behind the facility. The resident has since moved to a higher level of care.

The inspection was an unannounced complaint investigation visit triggered by an allegation that facility staff were not responding to call buttons in a timely manner.

The investigation substantiated the allegation that staff response times to resident call buttons were delayed, with documented response times exceeding 15 minutes and reaching as long as 107 minutes, posing potential health, safety, and personal rights risks to residents.

The complaint was substantiated based on interviews with staff and residents, and review of call button logs for multiple residents showing delayed response times. The allegation was that staff were not responding to call buttons in a timely manner.

The inspection was an unannounced complaint investigation visit conducted in response to a complaint received on 2023-12-01 alleging that facility staff restrained a resident by placing wheelchairs or obstacles to prevent the resident from getting out of bed.

The investigation included interviews with staff and residents, review of medical and incident records, and was unable to substantiate the allegation. The Department found insufficient evidence to prove the alleged violation occurred and classified the complaint as unsubstantiated.

The complaint alleged that staff restrained a resident by placing wheelchairs or obstacles to prevent the resident from getting out of bed. The investigation included interviews with five staff members and two residents, review of the resident's physician report and level of care assessments, and examination of incident reports and medication records. The allegation was found to be unsubstantiated due to lack of preponderance of evidence.

The inspection was conducted as a required unannounced annual inspection of the facility.

The facility was toured and inspected including common areas, resident apartments, kitchen, dining, and medication storage. The facility appeared clean, well-maintained, and in substantial compliance with regulations. No deficiencies were cited during the inspection.

The inspection was an unannounced complaint investigation visit triggered by allegations received on 11/29/2022 regarding neglect of residents' needs and overmedication at the facility.

The investigation substantiated the allegation that facility staff neglected residents' needs, specifically failing to keep incontinent residents clean and dry, posing immediate health and safety risks. Another allegation regarding residents being overmedicated was found to be unsubstantiated with no deficiencies cited.

The complaint investigation was substantiated for neglect related to residents being left in soiled briefs and inadequate toileting assistance, with staffing issues noted. The allegation of overmedication was unsubstantiated after review of medication records and interviews.

The inspection was an unannounced Required-1 Year Inspection focusing on the infection control domain to ensure compliance with health and safety standards.

The facility was found to be in substantial compliance with no immediate health, safety, or personal rights violations observed. No deficiencies were cited as a result of the inspection.

The inspection was an unannounced complaint investigation visit conducted in response to a complaint received on 2022-02-02 alleging that a resident sustained a fracture while in care and unlawful eviction.

The investigation found that the resident did sustain fractures from a fall but the facility took appropriate measures and timely medical attention was provided. The allegation of resident fracture was unsubstantiated due to insufficient evidence of violation. The allegation of unlawful eviction was found to be unfounded, meaning it was false or without reasonable basis.

The complaint involved two main allegations: 1) Resident sustained fracture while in care, and 2) Unlawful eviction. The fracture allegation was unsubstantiated after review of medical records and interviews. The unlawful eviction allegation was unfounded based on interviews and lack of eviction notice to the resident's responsible party.

Unannounced complaint investigation visit conducted in response to complaints alleging that facility staff did not return to assist a resident resulting in a fall and that the facility did not notify the responsible party of a change in the resident's condition.

The investigation found both allegations to be unsubstantiated after reviewing resident records, physician reports, staff interviews, and facility documentation. The facility was unable to provide some call log documents, and some staff involved were no longer employed. Notifications to the resident's responsible party regarding changes in care were documented.

The complaint alleged that facility staff left a resident unassisted in the shower resulting in a fall and that the facility failed to notify the responsible party of changes in the resident's condition. The investigation found insufficient evidence to substantiate these allegations, concluding them as unsubstantiated.

The inspection was an unannounced Required-1 Year Inspection focusing on the infection control domain, conducted to ensure health and safety compliance at the facility.

The facility was found to be in substantial compliance with no immediate health, safety, or personal rights violations observed. No deficiencies were cited as a result of the inspection.

The inspection was an unannounced complaint investigation visit triggered by complaints received on 2021-04-15 alleging inadequate care and supervision, insufficient staffing, and inadequate food service to residents.

The investigation substantiated allegations of inadequate care and supervision, insufficient staffing, and inadequate food service, citing delays and missed assistance to residents and meal issues. Other allegations including resident death, reappraisal, staff yelling, and inadequate record keeping were unsubstantiated or unfounded. The facility was found to be clean and well maintained with some inoperable kitchen equipment but alternative equipment available.

The complaint investigation was substantiated for allegations of inadequate care and supervision, insufficient staffing, and inadequate food service. The complaint was unsubstantiated for allegations of resident death, lack of resident reappraisal, staff yelling at residents, and inadequate record keeping. The complaint of facility disrepair was found to be unfounded.

An unannounced complaint investigation visit was conducted in response to allegations of personal rights violations, lack of supervision resulting in resident wandering, and lack of staff training.

The investigation found no substantiated evidence to support the allegations. Staff interviews and record reviews indicated that residents involved were transferred out due to change of conditions, and no violations were confirmed. No deficiencies were cited during the exit interview.

The complaint alleged staff were yelling at residents, residents were wandering away from the facility due to lack of supervision, and staff lacked proper training. The findings were unsubstantiated due to insufficient evidence.

The inspection visit was an unannounced complaint investigation triggered by a complaint received on 2020-12-18 alleging that staff did not administer a resident's medication per physician's order.

The investigation found that the medication was signed off by staff as given, but medication notes indicated the resident refused the medication on two occasions. The facility's medication refusal policy was reviewed, and the complaint was determined to be unsubstantiated due to insufficient evidence to prove the alleged violation occurred.

The complaint was unsubstantiated. Although the allegation may have been valid, there was not a preponderance of evidence to prove the violation occurred.

Unannounced complaint investigation visit conducted in response to a complaint received on 2020-12-18 regarding staff failure to notify a resident's responsible party of missed medication.

The investigation found that staff did not notify the resident's responsible party or primary care physician about missed medication despite documentation showing medication refusal. The allegation was substantiated based on interviews and record reviews. Deficiencies were cited related to failure to provide required reports to the licensing agency and responsible parties within seven days.

Complaint was substantiated. The allegation that staff did not notify the resident's responsible party of missed medication was found valid based on evidence including interviews and document reviews.