342700333-3-10-2023-25-AS-KHOS-CQKP29-20230404105536

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 342700333
Report Date: 03/10/2023
Date Signed: 03/10/2023 04:47:35 PM

Substantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 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
09/22/2022 and conducted by Evaluator Michael Hood

COMPLAINT CONTROL NUMBER: 25-AS-20220922122133

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: 99	DATE:	03/10/2023
		UNANNOUNCED	TIME BEGAN:	04:15 PM
MET WITH:	Jayvee Whitney, Resident Care Director		TIME COMPLETED:	05:00 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Facility is mismanaging medications

INVESTIGATION FINDINGS:

1
2
3
4
5
6
7
8
9
10
11
12
13

Licensing Program Analyst (LPA) Michael Hood arrived at the facility and met with Resident Care Director (RCD), Jayvee Whitney, to deliver findings into the complaint allegation listed above. LPA wore a surgical mask. Facility staff wore masks while on the premises.

During the investigation, LPA conducted interviews, conducted 2 medication counts, and requested documentation pertinent to the investigation.

The results of the investigation are as follows:

Allegation: Facility is mismanaging medications

** 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: 03/10/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/10/2023

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 4

Control Number 25-AS-20220922122133

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 2525 NATOMAS PARK DR STE 270
SACRAMENTO, CA 95833

FACILITY NAME: FAIR OAKS ESTATES INC	FACILITY NUMBER: 342700333
	VISIT DATE: 03/10/2023

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

During inspection conducted on 10/19/2022 and 3/6/2023, LPA conducted a medication count for residents R1, R2, and R3, comparing each resident’s Centrally Stored Medication Form (CSM) with medications centrally stored for the resident. On 10/19/2022, LPA observed R1 and R2 having multiple medications under what should have been available after taking any missed or refused medications listed on R1's and R2's medication chart (MAR) into account. On 3/6/2023, LPA observed R1 had multiple medications with no start date listed to identify the correct count. LPA also observed R2 to have 1 medication over the documented amount and R3 to have 1 medication lower than the documented amount. Neither errors for R2 and R3 were documented on their MARs.

Based on medication counts and records reviewed, the preponderance of evidence standards have been met. Therefore, the above allegation is found to be SUBSTANTIATED. Due to facility receiving a citation regarding the same violation in a separate inspection conducted on 3/10/2023, no additional citations will be issued regarding allegation.

Exit interview was conducted with RCD. A copy of this report was provided. The 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: 03/10/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/10/2023

LIC9099 (FAS) - (06/04)

Page: 2 of 4

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 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
09/22/2022 and conducted by Evaluator Michael Hood

COMPLAINT CONTROL NUMBER: 25-AS-20220922122133

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: 99	DATE:	03/10/2023
		UNANNOUNCED	TIME BEGAN:	04:15 PM
MET WITH:	Jayvee Whitney, Resident Care Director		TIME COMPLETED:	05:00 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Facility does not have sufficient staff to meet residents' care needs

INVESTIGATION FINDINGS:

1
2
3
4
5
6
7
8
9
10
11
12
13

Licensing Program Analyst (LPA) Michael Hood arrived at the facility and met with Resident Care Director (RCD), Jayvee Whitney, to deliver findings into the complaint allegation listed above. LPA wore a surgical 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 does not have sufficient staff to meet residents' care needs

** Report continued on 9099-C **

Unsubstantiated

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: 03/10/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/10/2023

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 4

Control Number 25-AS-20220922122133

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 2525 NATOMAS PARK DR STE 270
SACRAMENTO, CA 95833

FACILITY NAME: FAIR OAKS ESTATES INC	FACILITY NUMBER: 342700333
	VISIT DATE: 03/10/2023

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

Interviews conducted with staff members S1, S2, S3, S4, S5, and residents R3, R4, and R5 indicated that the facility has sufficient staffing to meet the care needs of the residents. Interviews with R3, R4, and R5 indicated that they do not have any issues receiving assistance from staff for their care needs.

Based on interviews conducted, the preponderance of evidence standards have not been met. Therefore, the above allegation is found to be UNSUBSTANTIATED. A finding that a complaint allegation 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 was conducted with RCD. A copy of this report was provided. The 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: 03/10/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/10/2023

LIC9099 (FAS) - (06/04)

Page: 4 of 4