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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 342700333
Report Date: 08/01/2023
Date Signed: 08/01/2023 04:10:07 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, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
This is an official report of an unannounced visit/investigation of a complaint received in our office on
06/01/2023 and conducted by Evaluator Kevin Mknelly
COMPLAINT CONTROL NUMBER: 59-AS-20230601112833
FACILITY NAME:FAIR OAKS ESTATES INCFACILITY NUMBER:
342700333
ADMINISTRATOR:SAROAY, PARVEENFACILITY TYPE:
740
ADDRESS:8845 FAIR OAKS BLVDTELEPHONE:
(916) 944-2077
CITY:CARMICHAELSTATE: CAZIP CODE:
95608
CAPACITY:106CENSUS: 101DATE:
08/01/2023
UNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Parveen SaroayTIME COMPLETED:
04:15 PM
ALLEGATION(S):
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Resident did not have a current LIC 602 at admission
Residents personal rights violated
Medications not refilled before supplies run out
Restricted health conditions not managed
INVESTIGATION FINDINGS:
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On 8/1/23, Licensing Program Analyst (LPA) Kevin Mknelly spoke to Administrator, Parveen Saroay, to deliver complaint findings for the above allegation.

LPA reviewed resident records, facility records and conducted extensive interviews.
LPA finds that the allegations cited above are substantiated.

Resident did not have a current LIC 602 at admission- Records review found that R1 was admitted 0n 5/31/23. Records provided by Administrator showed R1's physician's report (LIC 602) at admission was dated exam date 3/25/22, signature date 4/14/22 and R1 has a diagnosis of dementia.

Residents personal rights violated- Records found that R2 is diagnosed with dementia and has a behavior management plan for unwanted touching of female staff and female residents. R2's care plan directs staff to monitor R2's location when R2 is out of their room and intervene when R1 approaches female residents.
Interviews with caregivers found that as R2 is not 1:1, staff other duties leave many times when R2 is not
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Maribeth SentyTELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Kevin MknellyTELEPHONE: (209) 814-1925
LICENSING EVALUATOR SIGNATURE:

DATE: 08/01/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/01/2023
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
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
This is an official report of an unannounced visit/investigation of a complaint received in our office on
06/01/2023 and conducted by Evaluator Kevin Mknelly
COMPLAINT CONTROL NUMBER: 59-AS-20230601112833

FACILITY NAME:FAIR OAKS ESTATES INCFACILITY NUMBER:
342700333
ADMINISTRATOR:SAROAY, PARVEENFACILITY TYPE:
740
ADDRESS:8845 FAIR OAKS BLVDTELEPHONE:
(916) 944-2077
CITY:CARMICHAELSTATE: CAZIP CODE:
95608
CAPACITY:106CENSUS: DATE:
08/01/2023
UNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Parveen SaroayTIME COMPLETED:
04:15 PM
ALLEGATION(S):
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Staff fail to secure medications
INVESTIGATION FINDINGS:
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 On 8/1/23, Licensing Program Analyst (LPA) Kevin Mknelly conducted an unannounced complaint investigation visit to deliver the findings for the above allegations and met with xxx xxx.
LPA conducted inspectios, records review and extensive interviews.
LPA is unable to find and or meet the preponderance, per policy.
The allegation was that i the memory care unit, staff hang the medication room keeys outside of the medication room which leaves medication unsecured from residnents. Inspections and interviews found that staff would at times hang the keys to the room hanging outside the med room. However, medication technician staff would keep medication drawer and cabinet keys with them at all times. No resident access to medications were found during this investigation.
As a result of this investigation, LPA finds allegation to be (US)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 with administrator and report provided..
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Maribeth SentyTELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Kevin MknellyTELEPHONE: (209) 814-1925
LICENSING EVALUATOR SIGNATURE:

DATE: 08/01/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/01/2023
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 59-AS-20230601112833
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME: FAIR OAKS ESTATES INC
FACILITY NUMBER: 342700333
VISIT DATE: 08/01/2023
NARRATIVE
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 monitored. On 5/8/23, staff noted in R2's progress notes that at 11:48 R2 touched R3 in the lobby. Staff told R2 to stop and caregivers were notified. Then on 5/8/23, at 12:53, R2 then touched R4. On 5/15/23 and 6/1/23 progress notes similar unwanted touching of two other residents. R1's behavior was previously investigated and safety measures discussed with the Administrator to include measures to be in place for the safety of other residents.

Medications not refilled before supplies run out- LPA reviewed medication records for R5 and R6. Centrally Stored medication records, medication administration records and interviews found R5 and R6 had periods in May 2023 where medications were not administered with notations by staff of medication not available/ back ordered. Interviews found that the refill system lacked clarity of the process from refill request to tracking of refill delivery before R5 or R6 medication supply ran out. Staff were unable to provide records of physician contact or CCL reporting when R5 and R6 medications were not provided as prescribed.

Restricted health conditions not manage- LPA interviews of residents and staff found that staff, at times administered R7's insulin injections. Interviews found R7 is physically capable of administering their own inject. However, R7 would at times be resistant to administer their own injection so for expediency staff administer injections.

As a result of this investigation, LPA finds allegation to be (S) Substantiated - A finding that the complaint is Substantiated means that the allegation is valid because the preponderance of the evidence standard has been met. The following deficiencies were cited on 9099-D, per Title 22 Regulations, Division 6. (A)This poses an immediate Health and Safety risk to clients/residents in care. (B) This poses a potential Health and Safety risk, or personal rights violation, to clients/residents in care.

Report reviewed with Admin . Copy of this report and appeal rights provided.
SUPERVISOR'S NAME: Maribeth SentyTELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Kevin MknellyTELEPHONE: (209) 814-1925
LICENSING EVALUATOR SIGNATURE:

DATE: 08/01/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/01/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 4
Control Number 59-AS-20230601112833
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: FAIR OAKS ESTATES INC
FACILITY NUMBER: 342700333
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/01/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
08/15/2023
Section Cited
CCR
87465(a)(4)
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Incidental Medical and Dental Care (a)
(4) The licensee shall assist residents with self-administered medications as needed. This requirement was not met based on records review and interviews that in May 2023 R5 and R6 miseed medications.This posed an immediate risk.
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licensee has held a meeting with the primary pharmacy to resolve ordering.
Licensee will Will submit a detailed written procedure for ordering, tracking, logging and communication of medications ordered, when low but not refilled yet to received by the POC date of 8/15/23.
Type B
08/15/2023
Section Cited
CCR
87468.1(a)(1)
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87468.1 Personal Rights of Residents in All Facilities (a) Residents... shall have ... personal rights: (1) To be accorded dignity in their personal relationships ..., residents, ...
This requirement was not met based on records and interviews of R1 violating other's personal rights. Posed and immediate risk.
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Licensee will submit a detailed care plan for R2 that includes measurable monitoring, interventions and staff communication to address R2's touching of others as well as R2's personal rights to leave their room.
POC date 8/15/23.
Type B
08/15/2023
Section Cited
CCR
87465(a)(5)
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Incidental Medical and Dental Care (a)( 5) Facility staff, except those authorized by law, shall not administer injections,... This requirement was not met based on staff and resident statements that R7 was administered injections of insulin by unauthorized staff. This posed a potential risk to R7.
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Licensee will conduct a meeting with R7 to educate R7 doing their own injestions when needed. Licensee will conduct staff retraining on this regulation with all med techs.
Licensee will submit proof of resident education and staff training by the POC date of 8/15/23
Type B
08/15/2023
Section Cited
CCR
87458(a)
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Medical Assessment (a) Prior to a person's acceptance as a resident... documentation of a medical assessment, signed by a physician, made within the last year. This requirement was not met as evidenced by records review that found R1 admitted with an expired LIC 602. This posed a risk.
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Licensee will submit a statement that all resident physician reports are current as well as a plan for regular records audit by the POC date of 8/15/23.
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 SentyTELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Kevin MknellyTELEPHONE: (209) 814-1925
LICENSING EVALUATOR SIGNATURE:

DATE: 08/01/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/01/2023
LIC9099 (FAS) - (06/04)
Page: 4 of 4