342700333-9-26-2023-59-AS-MSEY-CW4SSG-20230928140756

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 342700333
Report Date: 09/26/2023
Date Signed: 09/26/2023 04:17:35 PM

Unsubstantiated

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
08/21/2023 and conducted by Evaluator Angela Hood

COMPLAINT CONTROL NUMBER: 59-AS-20230821151702

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: 100	DATE:	09/26/2023
		UNANNOUNCED	TIME BEGAN:	02:00 PM
MET WITH:	Parveen Saroay, Executive Director		TIME COMPLETED:	04:35 PM

ALLEGATION(S):

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-Staff did not ensure residents' oxygen tanks were full
-Resident sustained injury while in care
-Staff are not sufficiently trained

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Angela Hood arrived at the care home today, 9/26/23, and met with the Executive Director, Parveen Saraoy, to deliver complaint investigation findings into the allegations listed above.

During the course of the investigation, LPA conducted interviews and obtained documentation pertinent to the investigation.

*********************************************Continued on LIC9099-C******************************************************

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Maribeth Senty	TELEPHONE: (916) 214-0485
LICENSING EVALUATOR NAME: Angela Hood	TELEPHONE: 650-676-0390
LICENSING EVALUATOR SIGNATURE:	DATE: 09/26/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/26/2023

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 59-AS-20230821151702

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: 09/26/2023

NARRATIVE

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Allegation: Staff did not ensure residents' oxygen tanks were full.
The complaint is regarding concern that the facility is not refilling resident (R1's) portable oxygen tanks. On 9/13/23, LPA observed that R1's two (2) portable oxygen tanks were full. The Resident Care Coordinator (S5) demonstrated how staff fill the portable tanks by utilizing R1's continuous oxygen concentrator in their room. LPA observed that R1 was using the continuous oxygen concentrator and the nasal canula was in place. Interview with R1 indicated that the facility staff are meeting all of their care needs.

On 9/20/23, LPA observed resident (R2's) portable oxygen tanks and there were three (3) full tanks in their room. R2 also uses a continuous oxygen concentrator. R2 was out of the community and was using a portable tank. Interview with R2 indicated that they have never had any issues with having empty portable oxygen tanks. R2 indicated that the facility will contact the oxygen tank company to request new tanks when needed.

Interview with staff (S1 & S3) indicated that they have never noticed R1 to have empty portable oxygen tanks. Interviews with staff (S2 & S5), S1,and S3 indicated that, if the portable oxygen tanks get low, they are refilled by staff using the oxygen concentrator in R1's room.

Allegation: Resident sustained injury while in care.
The complaint is regarding concern that staff provided R1 a shower while on hospice and R1 hit their head in the shower. According to the facility incident report dated 8/20/23 and the Unusual Incident/Injury Report LIC624 dated 8/24/23, S1 assisted R1 with a shower and, while R1 was transferring out of the shower, they bumped their head on the wall. The facility incident report and the LIC624 indicated that R1 was not sent to the hospital for evaluation. Interview with S1 indicated that, when they arrived to work on 8/20/23, they checked R1's ADLs indicating that it was R1's shower day. S1 indicated that they did not know that R1 was on hospice as they were newly hired at the care home. R1 indicated that, since the incident, they were taught that there is an "H" in the ADL section of the facility system indicating when a resident is receiving hospice care. Interview with hospice nurse indicated that facility care staff can provide showers to residents when they are receiving hospice care.

******************************************Continued on LIC9099-C**************************************************

SUPERVISOR'S NAME: Maribeth Senty	TELEPHONE: (916) 214-0485
LICENSING EVALUATOR NAME: Angela Hood	TELEPHONE: 650-676-0390
LICENSING EVALUATOR SIGNATURE:	DATE: 09/26/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/26/2023

LIC9099 (FAS) - (06/04)

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Control Number 59-AS-20230821151702

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: 09/26/2023

NARRATIVE

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Allegation: Staff are not sufficiently trained.
The complaint is regarding concern that S1, who provided R1 a shower, was not properly trained. LPA reviewed training documentation for S1 and S2. S1 has the required 40 hours of training. S2 has the required 40 hours of training with an additional 20 hours of training for providing medication to residents in care.

Based on observation, interviews conducted, and documentation reviewed, although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur. Therefore, the allegations are UNSUBSTANTIATED. No deficiencies are being cited during this visit.

Exit interview conducted. A copy of the report was provided.

SUPERVISOR'S NAME: Maribeth Senty	TELEPHONE: (916) 214-0485
LICENSING EVALUATOR NAME: Angela Hood	TELEPHONE: 650-676-0390
LICENSING EVALUATOR SIGNATURE:	DATE: 09/26/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/26/2023

LIC9099 (FAS) - (06/04)

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