342700333-2-12-2024-59-AS-MSEY-D2PRM2-20240222120801

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 342700333
Report Date: 02/12/2024
Date Signed: 02/12/2024 05:24:45 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
08/25/2023 and conducted by Evaluator Angela Hood

COMPLAINT CONTROL NUMBER: 59-AS-20230825082432

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: 101	DATE:	02/12/2024
		UNANNOUNCED	TIME BEGAN:	12:25 PM
MET WITH:	Executive Director, Parveen Saroay		TIME COMPLETED:	02:00 PM

ALLEGATION(S):

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-Failure to seek timely medical treatment resulted in resident being hospitalized.
-Staff neglected to provide care to resident

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Angela Hood arrived unannounced at the care home today, 2/12/24, and met with the Executive Director, Parveen Saroay, to deliver complaint investigation findings into the above stated allegations.

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

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

Substantiated

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: 02/12/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/12/2024

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-20230825082432

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: 02/12/2024

NARRATIVE

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According to records reviewed and staff interviews, resident (R1’s) catheter was observed to be leaking on 8/15/23 for an unknown reason and Home Health was notified. On 8/16/23, Home Health did not conduct a visit with R1. On 8/16/23, staff reported to facility manager that R1 had a decrease in urine output, which was not common. However, no further attempts were made by the facility to contact Home Health. Also, the facility did not seek medical attention for R1’s decrease in urine output or the leaking catheter. On 8/17/23, staff reported R1 continued to have a decrease in urine output and appeared pale and ill. Despite R1’s symptoms, R1 was transported to day program and the facility did not communicate the reported information to Home Health, R1’s day program, or R1’s responsible party.

Upon arrival to day program, the program staff immediately observed R1 was ill and had no urine output in their catheter. Day program staff notified R1’s responsible party. Subsequently, R1 was sent to the hospital and diagnosed with severe sepsis secondary to pseudomonas bacteremia, an acute kidney injury, and a tear at the urethral meatus.

The facility’s Catheter Care Policy states that staff will “monitor skin area where catheter is inserted for any redness or swollen discharge, if any of those indication appear you must notify Med Tech immediately.” Home Health records and interview with Home Health nurse indicated that staff were trained to wash the catheter, including the bag, tubing, and penis daily, checking for signs of infection such as discharge or leaking urine. However, multiple staff interviews indicated that staff were not trained to check or wash the area where R1’s catheter was inserted in the penis. Multiple staff indicated that they did not conduct regular checks on R1’s catheter insertion site and did not observe a tear in R1’s urethral meatus.

Based on interviews conducted 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. As a result of the resident’s serious bodily injury, an immediate civil penalty per Health and Safety Code § 1548 in the amount of $500 for the date of 2/12/24 is assessed for a violation that the Department determines resulted in the injury or illness of a person in care. An additional civil penalty assessment is under review and a determination is pending. LPA will return on a future date to assess an additional civil penalty if warranted.

Exit interview conducted. A copy of this report and appeal rights were provided. Signature on these forms acknowledges receipt of these documents.

SUPERVISOR'S NAME: Maribeth Senty	TELEPHONE: (916) 214-0485
LICENSING EVALUATOR NAME: Angela Hood	TELEPHONE: 650-676-0390
LICENSING EVALUATOR SIGNATURE:	DATE: 02/12/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/12/2024

LIC9099 (FAS) - (06/04)

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Control Number 59-AS-20230825082432

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: 02/12/2024

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 02/13/2024 Section Cited CCR 87465(a)(1)	1 2 3 4 5 6 7	87465 Incidental Medical and Dental Care (a) A plan for incidental medical and dental care shall be developed by each facility. The plan shall encourage routine medical and dental care and provide for assistance in obtaining such care, by compliance with the following: (1) The licensee shall arrange, or assist in arranging, for medical and dental care appropriate to the conditions and needs of residents. This requirement is not met as evidenced by:	1 2 3 4 5 6 7	Facility agrees to create a plan to ensure that, when a resident has a change in condition, the facility will arrange or assist in arranging appropriate medical care. Facility will also conduct a training with staff regarding the importance of resident observation and seeking timely medical attention and submit to LPA by the POC due date of 2/13/24.
	8 9 10 11 12 13 14	Based on interviews conducted and records reviewed, the facility did not ensure resident (R1) received timely medical care for their leaking catheter and lack of urine output, which posed an immediate health, safety, and personal rights risk to residents in care.	8 9 10 11 12 13 14	An immediate civil penalty of $500 was assessed today per Health and Safety Code § 1548 due to a violation that the Department determines resulted in the injury or illness of a person in care.
Type A 02/13/2024 Section Cited CCR 87464(f)(1)	1 2 3 4 5 6 7	87464 Basic Services (f) Basic services shall at a minimum include: (1) Care and supervision as defined in Section 87101(c)(3) and Health and Safety Code section 1569.2(c). This requirement is not met as evidenced by:	1 2 3 4 5 6 7	Facility agrees to complete a statement of understanding as well as conduct a training with staff regarding the importance of following home health instructions and facility policies and submit to LPA by the POC due date of 2/13/24.
	8 9 10 11 12 13 14	Based on interviews conducted and records reviewed, the facility staff did not conduct regular checks on R1’s catheter insertion site as instructed by home health and facility policy, which posed an immediate health, safety, and personal rights risk to residents in care.	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: Angela Hood	TELEPHONE: 650-676-0390
LICENSING EVALUATOR SIGNATURE:	DATE: 02/12/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/12/2024

LIC9099 (FAS) - (06/04)

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