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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 342700333
Report Date: 12/02/2021
Date Signed: 12/02/2021 04:19:17 PM



STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 520 COHASSET RD., STE. 170
CHICO, CA 95926
This is an official report of an unannounced visit/investigation of a complaint received in our office on
11/10/2021 and conducted by Evaluator Kevin Mknelly
COMPLAINT CONTROL NUMBER: 25-AS-20211110122149
FACILITY NAME:FAIR OAKS ESTATES INCFACILITY NUMBER:
342700333
ADMINISTRATOR:SAROAY, PARVEENFACILITY TYPE:
740
ADDRESS:8845 FAIR OAKS BLVDTELEPHONE:
(916) 944-2077
CITY:CARMICHAELSTATE: CAZIP CODE:
95608
CAPACITY:106CENSUS: 78DATE:
12/02/2021
UNANNOUNCEDTIME BEGAN:
02:15 PM
MET WITH:Kirt HambergTIME COMPLETED:
04:30 PM
ALLEGATION(S):
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Facility is not following public health directive.
INVESTIGATION FINDINGS:
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On 12/2/21, Licensing Program Analyst (LPA) Kevin Mknelly spoke to Licensee of facility. The reson for the visit was to deliver findings for the allegation sited above. Upon entering the facility, analyst spoke with staff to pre-screen that the facility is COVID free. Analyst also self-screened for having no known symptoms or exposure. Analyst followed facility's screening, wore a surgical mask and maintained distance during the visit.

LPA reviewed facility records and conducted extensive interviews.
LPA finds that the allegation cited above are substantiated.
Public Health orders require incidents of staff or resident Covid 19 infections to be reported to Public Health and Community Care Licensing (CCL). Once reported facilities are required to provide testing results as directed for two consecutive weeks for all residents and staff until facility is cleared.

This facility has been in significant compliance with public health and CCL guidance and policy throughout much of the pandemic.
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Maribeth SentyTELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Kevin MknellyTELEPHONE: (209) 814-1925
LICENSING EVALUATOR SIGNATURE:

DATE: 12/02/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/02/2021
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 3
Control Number 25-AS-20211110122149
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 520 COHASSET RD., STE. 170
CHICO, CA 95926
FACILITY NAME: FAIR OAKS ESTATES INC
FACILITY NUMBER: 342700333
VISIT DATE: 12/02/2021
NARRATIVE
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 In this instance, however, proper reporting was not provided to CCL and insufficient testing was done in a timely manner. The incident of one Covid -19 positive staff did not spread further to other residents or staff. The facility has since tested all residents and employees. All have been found to be Covid-19 free.

As a result of this investigation, LPA finds allegation to be (S) Substantiated - A finding that the complaint is Substantiated means that the allegation is valid because the preponderance of the evidence standard has been met. The following deficiencies were cited on 9099-D, per Title 22 Regulations, Division 6. (A)This poses an immediate Health and Safety risk to clients/residents in care. (B) This poses a potential Health and Safety risk, or personal rights violation, to clients/residents in care.

This report was reviewed, copy provided and appeal rights provided.
SUPERVISOR'S NAME: Maribeth SentyTELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Kevin MknellyTELEPHONE: (209) 814-1925
LICENSING EVALUATOR SIGNATURE:

DATE: 12/02/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/02/2021
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 25-AS-20211110122149
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 520 COHASSET RD., STE. 170
CHICO, CA 95926

FACILITY NAME: FAIR OAKS ESTATES INC
FACILITY NUMBER: 342700333
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/02/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
12/16/2021
Section Cited
CCR
87468.1
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87468.1 Personal Rights of Residents in All Facilities. (a) Residents ... shall have all of the following personal rights:(2) To be accorded safe, healthful and comfortable accommodations,...
This requirement was not met as evidenced by
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Licensee will submit a statement of understanding of current public health orders and CCL PINs related to facility responsibilities in response to Covid 19 cases at the facility.

Statement to be submitted by the POC date of 12/16/21.
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following a staff member confirmed as Covid positive on 10/18/21, licensee failed to sufficiently test staff and residents in compliance with public health orders.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Maribeth SentyTELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Kevin MknellyTELEPHONE: (209) 814-1925
LICENSING EVALUATOR SIGNATURE:

DATE: 12/02/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/02/2021
LIC9099 (FAS) - (06/04)
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