198603531-3-12-2026-28-AS-DSIS-DS8TE7-20260316143926

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198603531
Report Date: 03/12/2026
Date Signed: 03/12/2026 12:25:53 PM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
MONTEREY PARK ASC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

This is an official report of an unannounced visit/investigation of a complaint received in our office on
02/17/2026 and conducted by Evaluator Daniel Konishi

PUBLIC

COMPLAINT CONTROL NUMBER: 28-AS-20260217084039

FACILITY NAME:	FAIR OAKS MANOR		FACILITY NUMBER:	198603531
ADMINISTRATOR:	MARYCEL CAMPOS		FACILITY TYPE:	735
ADDRESS:	1753 N. FAIR OAKS AVE.		TELEPHONE:	(626) 345-9788
CITY:	PASADENA	STATE: CA	ZIP CODE:	91103
CAPACITY:	14	CENSUS: 11	DATE:	03/12/2026
		UNANNOUNCED	TIME BEGAN:	08:45 AM
MET WITH:	Simplicia Gabia, DSP		TIME COMPLETED:	12:35 PM

ALLEGATION(S):

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Staff does not ensure to follow up with resident's doctor's appointments.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Daniel Konishi conducted an unannounced subsequent 10-day complaint visit and met with DSP, Simplicia Gabia and LPA discussed the purpose for today's visit to investigate the above allegation. LPA spoke with the Administrator, Marycel Campos over the phone and discussed the purpose of the visit.

On 2/19/2026, the initial investigation visit was conducted. The investigation consisted of the following:

The investigation consisted of the following: LPA requested copies of the staff roster and client roster. LPA interviewed the Administrator and Staff #1 (S1). LPA requested copies from Client #1 (C1’s) file such as Face Sheet, Physician’s Report, Doctor Appointment Notes, Hospital Notes, Client Notes, Special Incident Reports, and other pertinent documents which Administrator will send to the LPA by COB. LPA requested copies such as Staff Training and other pertinent documents which Administrator will send to the LPA by COB.

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: David Sicairos
LICENSING EVALUATOR NAME: Daniel Konishi
LICENSING EVALUATOR SIGNATURE:	DATE: 03/12/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/12/2026

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 28-AS-20260217084039

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
MONTEREY PARK ASC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: FAIR OAKS MANOR	FACILITY NUMBER: 198603531
	VISIT DATE: 03/12/2026

NARRATIVE

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On 2/27/2026, LPA interviewed Client #1 (C1) to Client #4 (C4), and S1 to Staff #3 (S3) over the phone.

On 3/4/2026, LPA interviewed Witness #1 (W1) and Witness #2 (W2) over the phone.

On 3/9/2026, LPA interviewed the Administrator over the phone. C1’s medical reports were obtained.

During today's visit, LPA Konishi obtained the following documents: C1’s Progress Notes from Pasadena Dept of Public Health (DPH). LPA also obtained from Admin, text message notes and emails regarding C1. LPA interviewed the Administrator and W1 and Witness #3 (W3) over the phone.

The investigation revealed the following: in regard to the allegation, “Staff does not ensure to follow up with resident's doctor's appointments.” It is alleged that there have been several requests for an ophthalmology evaluation, chest x-ray, and bloodwork and to date there has been no forward movement. These diagnostic studies are often time sensitive and C1 could potentially be diagnosed with optic neuritis. LPA interviewed C1 that denied the allegation stating that the facility has been following up with his doctor appointments. However, C1 could not recall on needing a ophthalmology evaluation. LPA interviewed one (1) out of two (2) clients that denied the allegation stating that the facility helps ensure following up with the client’s doctor appointments. One (1) out of two (2) clients did not confirm nor deny the allegation since that client schedules and follows up their own doctor appointments. However, both clients stated that the facility helps make sure that the client attends the doctor appointments. LPA attempted but was unable to interview an additional one (1) client since the client did not answer any of the questions. LPA interviewed two (2) out of two (2) witnesses that corroborated with the allegation stating that the facility has not been able to schedule follow-up appointments for C1 since there was a request for C1 to get a ophthalmology referral from C1’s physician on 12/22/2025. One (1) out of two (2) witnesses stated that C1 has not missed any doctor appointments. LPA interviewed Administrator that denied the allegation stating that the facility ensures that C1 and all clients’ doctor appointments are followed up. Three (3) out of three (3) staff could not confirm nor deny the allegation since they stated that the Administrator is responsible for scheduling and following up with C1’s doctor’s appointments. Administrator, three (3) out of three (3) staff stated that C1 has not missed any doctor appointments. The Administrator stated multiple phone calls were made to C1’s physician and the reason for the delay on scheduling the doctor’s appointment to get the ophthalmology evaluation prior was getting no response from the physician’s office and the physician’s office always being busy.
[Continue to LIC9099-C]

SUPERVISORS NAME: David Sicairos
LICENSING EVALUATOR NAME: Daniel Konishi
LICENSING EVALUATOR SIGNATURE:	DATE: 03/12/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/12/2026

LIC9099 (FAS) - (06/04)

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Control Number 28-AS-20260217084039

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
MONTEREY PARK ASC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: FAIR OAKS MANOR	FACILITY NUMBER: 198603531
	VISIT DATE: 03/12/2026

NARRATIVE

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LPA obtained from Administrator, text messages between the Administrator and Pasadena DPH that initially mentioned C1 need for an ophthalmology referral dated 12/22/2025. LPA obtained C1’s Progress Notes from Pasadena DPH that confirms that Pasadena DPH contacted the Administrator dated 12/22/2025 regarding C1’s need for a ophthalmology referral from C1’s physician. Based on C1’s Progress Notes, on 1/22/2026, C1 attended a virtual visit with a Medical Doctor (MD for a health evaluation. LPA reviewed C1’s chest x-ray lab report dated 1/22/2026 and C)1’s bloodwork lab report dated 1/28/2026. Based on C1’s Progress Notes, on 2/2/2026, C1 attended a TB clinic for a TB evaluation and was accompanied by facility staff. On 2/2/2026, Pasadena DPH notified Franklin D. Lanterman Regional Office regarding the need for C1 to change physician’s due to the lack of response and not receiving urgent medical referrals from C1’s physician. Based on C1’s Progress Notes, an email dated 2/9/2026 was sent from Pasadena DPH to the Administrator regarding if C1 has scheduled an ophthalmology appointment to rule out eye related issues. Per C1’s Progress Notes, Pasadena DPH attempted to contact C1’s physician regarding the ophthalmology referral numerous times dated 12/22/2025, 1/20/2026, and 1/27/2026 and got no response. On 2/11/2026, Pasadena DPH received a reply from C1’s physician’s office that an ophthalmology referral was sent out. Ultimately, there was a ophthalmology appointment that occurred on 3/9/2026 at 2:30pm. LPA has obtained C1’s ophthalmology report dated 3/9/2026 confirming that C1 went to the ophthalmology appointment on 3/9/2026. The Administrator stated that the facility is working together with the Frank D Lanterman Regional Center and Pasadena DPH on changing C1’s physician due to their current difficulty in scheduling doctor appointments with C1’s current physician. There seems to have been a lack of response from C1’s physician which possibly led to the delay of scheduling the ophthalmology appointment. There is not enough evidence to substantiate.

Based on statements and interviews conducted with staff, clients, review of client files and facility file records, there was not enough supportive evidence to concur with the reported allegation. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegations are UNSUBSTANTIATED.

Exit interview was held, and a copy of this report was provided to the DSP, Simplicia Gabia.

SUPERVISORS NAME: David Sicairos
LICENSING EVALUATOR NAME: Daniel Konishi
LICENSING EVALUATOR SIGNATURE:	DATE: 03/12/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/12/2026

LIC9099 (FAS) - (06/04)

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