342700333-9-29-2022-25-AS-KHOS-CK3PSB-20221010113405

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 342700333
Report Date: 09/29/2022
Date Signed: 09/29/2022 04:11:32 PM

Substantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CHICO - RESIDENTIAL, 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
09/15/2022 and conducted by Evaluator Michael Hood

COMPLAINT CONTROL NUMBER: 25-AS-20220915123806

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: 95	DATE:	09/29/2022
		UNANNOUNCED	TIME BEGAN:	02:10 PM
MET WITH:	Kayleigh Daniels, Resident Care Director		TIME COMPLETED:	04:30 PM

ALLEGATION(S):

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Facility refused to accept resident back from hospital

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Michael Hood arrived at the facility and met with Resident Care Director (RCD), Kayleigh Daniels, to deliver findings into the complaint allegation listed above. LPA wore an N-95 mask. Facility staff wore masks while on the premises.

During the investigation, LPA conducted interviews and requested documentation pertinent to the investigation.

The results of the investigation are as follows:

Allegation: Facility refused to accept resident back from hospital

** Report continued on 9099-C **

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Anthony Perez	TELEPHONE: (323) 485-4915
LICENSING EVALUATOR NAME: Michael Hood	TELEPHONE: (916) 531-7341
LICENSING EVALUATOR SIGNATURE:	DATE: 09/29/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/29/2022

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-20220915123806

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CHICO - RESIDENTIAL, 520 COHASSET RD., STE. 170
CHICO, CA 95926

FACILITY NAME: FAIR OAKS ESTATES INC	FACILITY NUMBER: 342700333
	VISIT DATE: 09/29/2022

NARRATIVE

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A complaint was received indicating that resident (R1) has been at Kaiser hospital since 8/23/2022. R1 was admitted to the hospital from their residence at Fair Oaks Estates Inc. Complaint indicated that hospital attempted to discharge R1 back to the facility, but facility refused to accept back resident from discharge.

Interview with Licensee indicated that resident moved out of the facility on a 51/50 hold on 8/23/2022 after seeing a psychiatric doctor who evaluated the resident as needing a higher level of care. Interview with RCD corroborated Licensee’s statements. R1 was transferred from the facility to the Kaiser hospital on a 51/50 hold on 8/23/2022 and did not have any other place of residence prior to transfer.

LPA reviewed R1’s resident file. R1’s Admission Agreement indicated that R1 was admitted as a resident at Fair Oaks Estates Inc on 8/3/2022. R1’s Preplacement Appraisal Information (LIC 603) is dated as completed on 8/22/2022 with a diagnosis of congestive heart failure, schizophrenia, and mild cognitive impairment. LPA reviewed R1’s medication documents and observed that R1 was refusing medications from time of admission to 8/23/2022 (date transferred to Kaiser hospital). R1’s Physician’s Report for RCFE (LIC 602) dated 6/22/2022 indicates R1 as having a primary diagnosis of Schizophrenia with no Dementia diagnosis. LPA observed two (2) assessments in R1’s file dated 8/3/2022 and 8/6/2022 indicating a change in condition.

While LPA observed documents demonstrating signs of R1 experiencing a change in condition, facility did not issue an eviction notice and did not inform Department of any intended action by the facility. When requested during visits conducted on 9/23/2022 and 9/29/2022, facility could not produce an eviction notice.

Based on interviews conducted by the department and records reviewed, the preponderance of evidence standards have been met. Therefore, the above allegation is found to be SUBSTANTIATED. Per California Code of Regulations, Title 22, Division 6, Chapter 8, a deficiency is being cited on the attached 9099-D page.

Exit interview was conducted with RCD. A copy of this report and appeal rights were provided. RCD's signature on these forms acknowledges receipt of these documents.

SUPERVISOR'S NAME: Anthony Perez	TELEPHONE: (323) 485-4915
LICENSING EVALUATOR NAME: Michael Hood	TELEPHONE: (916) 531-7341
LICENSING EVALUATOR SIGNATURE:	DATE: 09/29/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/29/2022

LIC9099 (FAS) - (06/04)

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Control Number 25-AS-20220915123806

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CHICO - RESIDENTIAL, 520 COHASSET RD., STE. 170
CHICO, CA 95926

FACILITY NAME: FAIR OAKS ESTATES INC	FACILITY NUMBER: 342700333
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 09/29/2022

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 10/14/2022 Section Cited CCR 87224(a)(4)	1 2 3 4 5 6 7	87224 Eviction Procedures (a) The licensee may evict a resident for one or more of the reasons listed in Section 87224(a)(1) through (5). Thirty (30) days written notice to the resident is required (…) (4) If, after admission, it is determined that the resident has a need not previously identified and a reappraisal has been conducted pursuant to Section 87463, and the licensee and the person who performs the reappraisal believe that the facility is not appropriate for the resident. This requirement is not met as evidenced by:	1 2 3 4 5 6 7	Facility will complete a statement of understanding regarding regulation 87224. Facility will submit statement of understanding to LPA by POC due date of 10/14/2022.
	8 9 10 11 12 13 14	Based on interviews conducted and records reviewed, the facility did not properly evict R1 after being evaluated by a psychiatric doctor indicating that R1 needed a higher level of care, which poses an potential health, safety, and personal rights risk to residents in care.	8 9 10 11 12 13 14
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
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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: Anthony Perez	TELEPHONE: (323) 485-4915
LICENSING EVALUATOR NAME: Michael Hood	TELEPHONE: (916) 531-7341
LICENSING EVALUATOR SIGNATURE:	DATE: 09/29/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/29/2022

LIC9099 (FAS) - (06/04)

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