342700333-7-10-2020-27-AS-MSEY-BRPSWU-20200720141456

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 342700333
Report Date: 07/10/2020
Date Signed: 07/10/2020 10:48:44 AM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

This is an official report of an unannounced visit/investigation of a complaint received in our office on
03/06/2020 and conducted by Evaluator Melana Llopis

PUBLIC

COMPLAINT CONTROL NUMBER: 27-AS-20200306160617

FACILITY NAME:	FAIR OAKS ESTATES INC		FACILITY NUMBER:	342700333
ADMINISTRATOR:	SAROAY, PARVEEN		FACILITY TYPE:	740
ADDRESS:	8845 FAIR OAKS BLVD		TELEPHONE:	(916) 944-2077
CITY:	CARMICHAEL	STATE: CA	ZIP CODE:	95608
CAPACITY:	106	CENSUS: 78	DATE:	07/10/2020
		UNANNOUNCED	TIME BEGAN:	08:45 AM
MET WITH:	Executive Director, Parveen Saroay		TIME COMPLETED:	11:00 AM

ALLEGATION(S):

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Resident (R1) was admitted to the hospital with a stage 3 ulcer due to facility neglect.
Staff did not provide a comfortable bed for resident.

INVESTIGATION FINDINGS:

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Licensing Program Analysts (LPAs) Llopis and Calzada arrived at the facility unannounced on 07/10/2020 to deliver the amended complaint findings for complaint 27-AS-20200306160617. LPAs explained the purpose of the visit with Executive Director (ED), Parveen Saroay.

Throughout the course of the investigation, the Department conducted multiple interviews with staff and key witness and reviewed documentation pertinent to the investigation.

***Continuation on 9099-C***

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Maribeth Senty	TELEPHONE: (916) 214-0485
LICENSING EVALUATOR NAME: Melana Llopis	TELEPHONE: 510-298-7052
LICENSING EVALUATOR SIGNATURE:	DATE: 07/10/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/10/2020

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 27-AS-20200306160617

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

FACILITY NAME: FAIR OAKS ESTATES INC	FACILITY NUMBER: 342700333
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 07/10/2020

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Request Denied Type A 07/24/2020 Section Cited CCR 87464(d)	1 2 3 4 5 6 7	Basic Services (d) A facility need not accept a particular resident for care. However, if a facility chooses to accept a particular resident for care, the facility shall be responsible for meeting the resident's needs as identified in the pre-admission appraisal specified in Section 87457, Pre-admission Appraisal and providing the other basic services specified below, either directly or through outside resources. This requirement was not met as evidenced by:	1 2 3 4 5 6 7	Licensee agrees to re-train staff on resident's refusal of care, and re-train Resident Care Director on assessment of resident before returning from the hospital, as well as require additional information from the hospital in writing regarding residents with pressure sores. Licensee will provide CCL via fax/email an agenda and completion of training by the POC date of 07/24/2020.
	8 9 10 11 12 13 14	Based on records reviewed and interviews conducted, the licensee did not meet resident (R1's) care needs by ensuring that resident was turned at least every two (2) hours which resulted in resident's pressure sore worsening and resident being admitted to the hospital which posed an immediate health and safety risk to resident in care.	8 9 10 11 12 13 14
Deficiency Dismissed Type B 07/24/2020 Section Cited CCR 87307(a)(2)(A)	1 2 3 4 5 6 7	Personal Accommodations and Services a) Living accommodations and grounds shall be related to the facility's function. The facility shall be large enough to provide comfortable living accommodations and privacy for the residents, staff, and others who may reside in the facility. The following provisions shall apply: (2) Resident bedrooms shall be provided which meet, at a minimum, the following requirements: (A) Bedrooms shall be large enough to allow for easy passage between and comfortable usage of beds and other required items of furniture specified below, and any resident assistant devices such as wheelchairs or walkers. This requirement was not met as evidenced by:	1 2 3 4 5 6 7	Moving forward the licensee agrees to include the following in staff training: confirmation of bed size being appropriate for resident's needs and care plan upon moving into facility and if not, to follow up as needed. Licensee will provide CCL via email/fax the additional training for staff by the POC date of 07/24/2020.
	8 9 10 11 12 13 14	Based on records reviewed and interviews conducted, resident (R1) was not provided an appropriate sized bed while in care. This posed a potential health and safety risk to resident.	8 9 10 11 12 13 14

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 Senty	TELEPHONE: (916) 214-0485
LICENSING EVALUATOR NAME: Melana Llopis	TELEPHONE: 510-298-7052
LICENSING EVALUATOR SIGNATURE:	DATE: 07/10/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/10/2020

LIC9099 (FAS) - (06/04)

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Control Number 27-AS-20200306160617

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

FACILITY NAME: FAIR OAKS ESTATES INC	FACILITY NUMBER: 342700333
	VISIT DATE: 07/10/2020

NARRATIVE

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The results of the investigation are as follows:

Allegation: Resident (R1) was admitted to the hospital with a stage 3 ulcer due to facility neglect.

Documentation reviewed and interviews conducted with facility staff and Resident Care Director revealed resident was receiving wound care from Home Health upon admission. Resident was admitted and assessed on 01/28/2020. Resident’s Assessment Care Plan completed by facility on 01/28/2020, indicates known uncooperative, disruptive and resistive behaviors. Resident’s Medical Assessment (LIC 602) dated on 01/27/2020 indicates resident’s primary diagnosis includes “skin problems,” and has a history of skin breakdown. On 01/30/2020, Home Health notes also state resident has a "history of skin breakdown and had a rash/wound." Home Health notes on 02/04/2020 reveal resident required repositioning every one -two (1-2) hours and topical ointment to be applied daily to wounds. Staff interviews stated the resident was a “high risk skin breakdown resident who refused to comply with repositioning and bathing on a routine basis and was verbally abusive to staff.” This was confirmed in various incident reports on 02/28/2020 and 03/03/2020. Knowing resident was non-compliant with care, the facility did not issue resident a 30 day notice stating they could not meet resident’s needs, thus resident’s wounds worsened while in the facility’s care. On 03/05/2020 resident was sent to the ER, admitted to the hospital, and diagnosed with stage three (3) pressure wound and was bleeding from the wound.

Based on information obtained during the investigation, the Department finds the above allegation to be SUBSTANTIATED. meaning that the allegation is valid because the preponderance of the evidence standard has been met.

Allegation: Staff did not provide a comfortable bed for resident

Interviews and documentation reviewed revealed on 01/28/2020 resident moved into the facility with a hospital bed provided by the facility. According to staff interviews, resident was a large individual and the twin size bed provided was an "inappropriate" size. In January 2020, the facility stated they ordered another bed through Home Health, however it was never received. Home Health notes dated on 02/14/2020 state it was "difficult to position patient due to [their] size and small bed.”

Based on the information obtained during the investigation, the Department finds the allegation to be SUBSTANTIATED, meaning that the allegation is valid because the preponderance of the evidence standard has been met.

Per California Code of Regulations, Title 22, Division 6, Chapter 8, deficiencies are being cited on 9099-D. Failure to correct the deficiencies by the noted due date may result in a penalty(ies) being assessed.

Exit interview conducted with Administrator. Copy of report and appeal rights left at the facility.

SUPERVISOR'S NAME: Maribeth Senty	TELEPHONE: (916) 214-0485
LICENSING EVALUATOR NAME: Melana Llopis	TELEPHONE: 510-298-7052
LICENSING EVALUATOR SIGNATURE:	DATE: 07/10/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/10/2020

LIC9099 (FAS) - (06/04)

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