342700333-6-29-2022-25-AS-MSEY-CG2NXT-20220705105139

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 342700333
Report Date: 06/29/2022
Date Signed: 06/29/2022 02:33:52 PM

Unfounded

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
04/12/2022 and conducted by Evaluator Sabrina Calzada

PUBLIC

COMPLAINT CONTROL NUMBER: 25-AS-20220412161740

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: 80	DATE:	06/29/2022
		UNANNOUNCED	TIME BEGAN:	02:15 PM
MET WITH:	Shahbaz Singh, Administrator		TIME COMPLETED:	02:40 PM

ALLEGATION(S):

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Resident was locked in her room
Resident unable to use the signal system

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Sabrina Calzada arrived unannounced to deliver findings to a complaint investigation for a complaint received on 4/12/2022. LPA met with Shahbaz Singh, Executive Director, and explained purpose of inspection. 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 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, and Narrative Charting Notes.

The results of the investigation are as follows:
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: 06/29/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/29/2022

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 25-AS-20220412161740

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: 06/29/2022

NARRATIVE

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9099C(1). Allegation: Resident was locked in her room.Allegation is that when resident (R1) responded to staff (S1) who used derogatory language with her, staff locked her in her room.

Staff (S1) stated she did not lock resident in her room and she is not sure if there is a lock on the door. S1 stated that if resident was yelling at her, she would "close the door so it wouldn't bother other residents" and walk out of the room to get another caregiver. A second caregiver stated that she doesn't recall hearing that resident was ever locked in her room and sometimes resident wanted her door open and sometimes she preferred it closed. Staff stated she did hear about resident having complaints about staff, S1, but she never witnessed any verbal or other abuse by S1. A third staff stated that resident wanted the door to her room open all of the time, as it was close to the medication room where staff was nearby. This same staff stated that resident mentioned to her one time that staff, S1, closed the door to her room and locks are only used on resident room doors if the room is vacant or if the resident accidentally locks it. This same staff stated she has never seen the door to resident's room closed. Floor manager confirmed resident's room locks for privacy from the inside and the Hospice case manager stated that she was not made aware of resident ever being locked in her room.

Based on information obtained, LPA Finds the allegation to be UNFOUNDED.

Allegation: Resident unable to use the signal system. Allegation is because resident is quadriplegic, she is not able access the signal system to call for assistance.

Staff (S1) stated that resident (R1) had access to the Med-Tech phone due to having both a personal cell phone and a separate device, "Alexa or Siri" and "would call all of the time, round the clock". Two additional staff stated that resident used her personal cell phone as well as the second device which displayed a different phone number when calling the Med Room and resident would use both numbers on a regular basis. Narrative charting notes document resident called on a very regular and frequent basis. Another staff stated that resident was also offered the use of a shoulder pad to call for assistance, upon move in and when her cell phone coverage was down for two days, and resident declined both times. Based on information obtained, LPA Finds the allegation to be UNFOUNDED.

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: 06/29/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/29/2022

LIC9099 (FAS) - (06/04)

Page: 3 of 3

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
04/12/2022 and conducted by Evaluator Sabrina Calzada

COMPLAINT CONTROL NUMBER: 25-AS-20220412161740

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:	DATE:	06/29/2022
		UNANNOUNCED	TIME BEGAN:	02:15 PM
MET WITH:			TIME COMPLETED:	02:40 PM

ALLEGATION(S):

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Facility staff did not treat resident with respect.

INVESTIGATION FINDINGS:

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Allegation: Facility staff did not treat resident with respect. Allegation is staff (S1) is mean and uses derogatory language with resident (R1)

Staff (S1) stated she never used derogatory language towards resident (R1) or any other residents and that resident used "foul language towards all of the staff" because she didn't want to wait for staff to assist her if they were busy with other residents. Floor manager stated she has never heard that S1 was verbally abusive or disrespectful to resident (R1) and always heard S1 address her with the prefix "Miss". Another staff stated she heard S1 "could be a little rude to everyone" with a third staff saying she observed S1 to be rude and use cuss words with resident, R1, and other residents as well as other staff. Administrator agrees to review Resident Rights with S1 individually. Elder Abuse was conducted for all staff last month.

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.

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: 06/29/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/29/2022

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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