342700333-6-23-2022-25-AS-MSEY-CFPRJ9-20220624130335

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 342700333
Report Date: 06/23/2022
Date Signed: 06/23/2022 06:47:25 PM

Unsubstantiated

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
03/28/2022 and conducted by Evaluator Sabrina Calzada

PUBLIC

COMPLAINT CONTROL NUMBER: 25-AS-20220328154407

FACILITY NAME:	FAIR OAKS ESTATES INC		FACILITY NUMBER:	342700333
ADMINISTRATOR:	SINGH, GURSHAHBAZ		FACILITY TYPE:	740
ADDRESS:	8845 FAIR OAKS BLVD		TELEPHONE:	(916) 944-2077
CITY:	CARMICHAEL	STATE: CA	ZIP CODE:	95608
CAPACITY:	106	CENSUS: 79	DATE:	06/23/2022
		UNANNOUNCED	TIME BEGAN:	03:30 PM
MET WITH:	Shahbaz Singh, Administrator		TIME COMPLETED:	06:00 PM

ALLEGATION(S):

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Staff verbally abuse residents
Staff is physically rough with residents

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Sabrina Calzada arrived unannounced to conclude a complaint investigation. LPA met with Angie Price, Floor Manager, and explained purpose of inspection. LPA later met with Shahbaz Singh, Executive Director.

Prior to initiating today's inspection, LPA completed required COVID-19 testing protocols and completed a daily self-screening questionnaire for symptoms of COVID-19 infection to affirm no COVID-19 related symptoms. Additionally, LPA was screened per Covid-19 precautionary measures upon entering the facility. LPA ensured she applied hand sanitizer before entering the facility and the following Personal Protective Equipment (PPE): surgical mask.

During today's inspection, LPA interviewed Floor Manager, (1) Med-Tech, (1) caregiver, and Hospice Case Manager.

cont on 9099C(1)..

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Maribeth Senty	TELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Sabrina Calzada	TELEPHONE: (510) 829-2133
LICENSING EVALUATOR SIGNATURE:	DATE: 06/23/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/23/2022

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 5

Control Number 25-AS-20220328154407

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: 06/23/2022

NARRATIVE

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9099C(1).During the investigation, LPA interviewed the Administrator, Marketing Director, Floor Manager, Hospice Case Manager , (3) Med-Techs, (2) caregivers and (3) residents. LPA reviewed documentation pertaining to resident (R1) including, but not limited to: Pre-Appraisal, Physician's Reports, Reappraisal, Narrative Charting Notes, and Repositioning Charts.

The results of the investigation are as follows;

Allegation: Staff verbally abuse residents.

Allegation is that caregiver/med-tech (S2) is verbally abusive and on Saturday, 03/26/2022, and Sunday night, 03/27/2022. S2 was screaming at the top of her lungs yelling at other residents. R2, R3 and R4 are other residents that have had issues with S2 and her verbal abuse.

Resident (R1) stated S2 yells at her when providing care. Interview with resident (R2) revealed that staff (S2) is not nice but could not provide any examples of S2 using any verbal abuse with her. Resident R3 stated in an interview that she has never heard any staff yell or cuss at residents and if there was an issue she would discuss it with a care manager. Resident (R4) was not available for an interview when LPA attempted to during the investigation.

Staff interviews provided conflicting information regarding if staff (S2) has ever made any inappropriate or rude comments to residents, including resident (R1). One staff stated she observed R1 to be crying one time after reporting S2 made an unkind comment to her and she has also observed S2 to be rude to other residents as well as staff. Another staff commented that S2 may be a little difficult to get along with but never witnessed any verbal abuse from her. S2 stated she has never used foul language or spoken inappropriately to any residents and resident R1 used derogatory language often with many staff, which caused (3) staff to quit. Multiple staff interviewed indicated that R1 would often yell at staff and call them inappropriate names. Narrative charting notes show R1 would yell and cuss on a regular basis.

Based on information obtained, LPA finds the allegation to be UNSUBSTANTIATED- A finding that the complaint 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.

cont on 9099C(2)..

SUPERVISOR'S NAME: Maribeth Senty	TELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Sabrina Calzada	TELEPHONE: (510) 829-2133
LICENSING EVALUATOR SIGNATURE:	DATE: 06/23/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/23/2022

LIC9099 (FAS) - (06/04)

Page: 2 of 5

Control Number 25-AS-20220328154407

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: 06/23/2022

NARRATIVE

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9099C(2).. Allegation: Staff is physically rough with residents.

Allegation is staff (S2) was rough physically with resident R1 and residents R2, R3 and R4.

Resident R1 stated S2 is rough with her when repositioning her. R2 stated that one time when S2 was helping her with the hoyer lift, the strap from the hoyer lift hit her in the face, explaining " My legs bumped into a pole on the strap of the hoyer lift and hit me in the face. Only one person does that and she has had training- she doesn't like me". Administrator stated he spoke with R2 following the incident and there were no injuries noted. Administrator agreed to conduct a follow up training with all staff on proper hoyer usage.
R3 stated she has never observed staff to handle residents roughly. R4 was unavailable for an interview during the investigation.

S2 stated that R1 required 2 caregivers to transfer or reposition her due to her being fragile and her illness. Floor Manager and other staff interviewed indicated that R1 was a "two person transfer because of R1's verbal abuse". One staff stated that she never observed S2 to be rough when providing care and R1 never complained about S2 or any other staff handling her roughly.

Based on information obtained, LPA finds the allegation to be UNSUBSTANTIATED- A finding that the complaint 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. Copy of report provided to Administrator.

SUPERVISOR'S NAME: Maribeth Senty	TELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Sabrina Calzada	TELEPHONE: (510) 829-2133
LICENSING EVALUATOR SIGNATURE:	DATE: 06/23/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/23/2022

LIC9099 (FAS) - (06/04)

Page: 5 of 5

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
03/28/2022 and conducted by Evaluator Sabrina Calzada

PUBLIC

COMPLAINT CONTROL NUMBER: 25-AS-20220328154407

FACILITY NAME:	FAIR OAKS ESTATES INC		FACILITY NUMBER:	342700333
ADMINISTRATOR:	SINGH, GURSHAHBAZ		FACILITY TYPE:	740
ADDRESS:	8845 FAIR OAKS BLVD		TELEPHONE:	(916) 944-2077
CITY:	CARMICHAEL	STATE: CA	ZIP CODE:	95608
CAPACITY:	79106	CENSUS: 79	DATE:	06/23/2022
		UNANNOUNCED	TIME BEGAN:	03:30 PM
MET WITH:	Shahbaz Singh, Administrator		TIME COMPLETED:	06:00 PM

ALLEGATION(S):

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Facility is not following resident's care plan

INVESTIGATION FINDINGS:

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During the investigation, LPA interveiwed Marketing Director, Floor Manager, Hospice Case Manager , (3) Med-Techs, (2) caregivers and (3) residents. LPA reviewed documentation pertaining to resident (R1) including, but not limited to: Pre-Appraisal, Physician's Reports, Reappraisal, Narrative Charting Notes, and Repositioning Chart.

The results of the investigation are as follows:

Allegation: Facility is not following resident's care plan

Allegation is that on Saturday,3/26/2922, at 10PM, R1 received her medications very late and on 3/27/22, at 11 PM, a caregiver from memory care finally put R1 in bed. Caregivers are not repositioning R1 every 2 hours.

cont on 9099C(1)..

Unfounded

Estimated Days of Completion:

SUPERVISOR'S NAME: Maribeth Senty	TELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Sabrina Calzada	TELEPHONE: (510) 829-2133
LICENSING EVALUATOR SIGNATURE:	DATE: 06/23/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/23/2022

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

LIC9099 (FAS) - (06/04)

Page: 3 of 5

Control Number 25-AS-20220328154407

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: 06/23/2022

NARRATIVE

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9099AC(1).. Multiple staff interviewed indicated that resident (R1) was receiving the care needed per her care plan with one staff stating staff will follow each resident’s care plan per the “Point Care” system monitor, located in each hallway, and check off the care as it is provided. All interviews confirmed that resident needed assistance with all ADL’s and staff was attending to resident multiple times daily, even after immediately providing care. In addition, resident was receiving hospice care services, including bathing, three times weekly.

LPA was provided with narrative notes for period 11/30/2021 through 4/10/2022. Narrative notes entered on 3/26/2022, at 10:10 pm, by staff (S2) note that staff (S1) went to take resident her 8:00 pm medications because she refused them, as she does every night at 8:00 pm. Notes entered on 3/27/2022, at 10:09 pm, by staff (S2) indicate that resident called her at 10:03 pm requesting medications and they were taken to resident. Staff (S2) entered notes on 3/27/2022 at 10:09 pm that at 10:03 pm, resident called for her medications and S2 took them to resident. Staff (S2) entered subsequent notes on 3/27/2022 at 11:27 pm to document that resident called staff (S2) again at 10:20 pm, requesting to be put to bed and staff informed resident she was assisting another resident and would assist her as soon as possible. Additionally, notes entered by different staff show that resident refused to take her scheduled medications when they were administered at 10:00 pm on 3/2/2022, 3/4/2022, 3/15/2022, 3/22/2022, 3/23/2022.

LPA reviewed documentation entitled “(R1) Repositioning Chart” for period 4/5/2022 through 4/14/2022 and observed staff to have signed and indicated the time resident was repositioned every two hours. Narrative charting notes reviewed also reflect on many days that staff was repositioning resident every two hours per care plan. Multiple staff interviews revealed that resident would call the Med-Room numerous times daily, even immediately following when care was just provided. Narrative charting notes reflect that resident would regularly make continuous calls throughout each day with a note entered on 12/7/2021 indicating resident had left 17 messages in total that day.

Based on information obtained during the investigation, LPA finds the allegation to be UNFOUNDED- meaning that the allegation was false, could not have happened and/or is without a reasonable basis.

Exit interview conducted and report provided.

SUPERVISOR'S NAME: Maribeth Senty	TELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Sabrina Calzada	TELEPHONE: (510) 829-2133
LICENSING EVALUATOR SIGNATURE:	DATE: 06/23/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/23/2022

LIC9099 (FAS) - (06/04)

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