342700333-4-8-2024-59-AS-MSEY-D48TED-20240411143942

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 342700333
Report Date: 04/08/2024
Date Signed: 04/08/2024 03:55:26 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
12/13/2023 and conducted by Evaluator Angela Hood

COMPLAINT CONTROL NUMBER: 59-AS-20231213090351

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:	DATE:	04/08/2024
		UNANNOUNCED	TIME BEGAN:	11:45 AM
MET WITH:	Parveen Saroay, Executive Director		TIME COMPLETED:	04:15 PM

ALLEGATION(S):

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-Staff neglect resulted in resident developing multiple medical conditions
-Staff did not address incontinent issues with appropriate representative

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Angela Hood arrived at the care home today, 4/8/24, and met with the Executive Director, Parveen Saroay, to deliver complaint investigation findings into the allegations listed above.

During the course of the investigation, the Department conducted interviews and obtained documentation pertinent to the investigation.
Allegation: Staff neglect resulted in multiple medical conditions.
Resident (R1’s) responsible party indicated that R1 had frequent falls, was on a strict diet, had plenty of water to drink, and had not had a Urinary Tract Infection (UTI) for several years prior to moving into the facility. Responsible party indicated that, within the first two weeks of R1 residing at the facility, they were witnessed eating sugary snacks, drinking sugary drinks and coffee, and only drinking approximately four ounces of water with their medications. It is believed by the responsible party that R1’s decline is due to their diet.
******************************************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: 04/08/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/08/2024

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 5

Control Number 59-AS-20231213090351

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: 04/08/2024

NARRATIVE

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Facility staff noted that R1 had several falls, decreased energy levels, and increased confusion. Facility staff also noted that R1 was skipping meals. Facility contacted R1’s Primary Care Physician (PCP) and reported R1’s change in condition, however, did not hear back from the PCP prior to R1’s hospitalization. Interviews conducted by the Department with staff indicated that none of the facility staff members were aware that R1 had a stage three pressure wound on their right heel despite R1 requiring one on one assistance with dressing and bathing. Facility staff noted that R1 had dry flaky skin on their right heel on 10/22/2023. Staff interviews also indicated that none of the staff were aware of any signs or symptoms of infection or any redness or swelling.

R1 was hospitalized from 11/9/2023-11/19/2023. Hospital records indicated that R1 was diagnosed with a UTI, severe sepsis, several fractured ribs, hypoglycemia, and a stage three pressure wound on their right heel upon arrival.

Allegation:
Staff did not address incontinent issues with appropriate representative.
Interview with Resident Care Director (RCD) indicated that, prior to R1 being sent to the hospital on 11/9/23, R1 was placed on a 72-hour watch to observe for any changes in R1’s condition. The facility noted that R1 was experiencing confusion on 11/7/23, which continued on 11/8/23. RCD stated that, during the 72-hour period, the facility provided courtesy services to R1 if any changes in condition were observed. RCD indicated that, as part of the courtesy services, facility staff were providing R1 assistance with toileting as incontinence issues were observed. According to R1’s Assessment dated 9/29/23, R1 was not incontinent. RCD stated that R1 was originally independent with toileting. RCD indicated that R1’s responsible party was not notified during the 72-hour period that the incontinence issues were observed.

Based on interviews conducted and records reviewed, the preponderance of evidence standards have been met. Therefore, the above allegations are found to be SUBSTANTIATED. Per California Code of Regulations, Title 22, Division 6, Chapter 8, deficiencies are 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 4/8/24 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 acknowledge 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: 04/08/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/08/2024

LIC9099 (FAS) - (06/04)

Page: 2 of 5

Control Number 59-AS-20231213090351

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: 04/08/2024

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 04/09/2024 Section Cited CCR 87466	1 2 3 4 5 6 7	87466 Observation of the Resident The licensee shall ensure that residents are regularly observed for changes in physical, mental, emotional and social functioning and that appropriate assistance is provided when such observation reveals unmet needs. When changes such as unusual weight gains or losses or deterioration of mental ability or a physical health condition are observed, the licensee shall ensure that such changes are documented and brought to the attention of the resident's physician and the resident's responsible person, if any. This requirement is not met as evidenced by:	1 2 3 4 5 6 7	Facility will conduct in-service training for staff regarding observation of residents. Facility will submit to LPA information regarding in-service training, including time and date of in-service and training material, by POC due date of 4/9/24.
	8 9 10 11 12 13 14	Based on records reviewed and interviews conducted facility staff did not observe resident (R1) in accordance with their care plan resulting in R1 sustaining a stage three pressure injury, which poses 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 B 04/22/2024 Section Cited CCR 87463(b)	1 2 3 4 5 6 7	87463 Reappraisals (b) The licensee shall immediately bring any such changes to the attention of the resident's physician and his family or responsible person. This requirement is not met as evidenced by:	1 2 3 4 5 6 7	Facility will conduct in-service training for staff regarding the importance of notifying a residents physician and responsible party when changes in condition are observed. Facility will submit to LPA information regarding in-service training , including time and date of in-service and training material, by POC due date of 4/22/24.
	8 9 10 11 12 13 14	Based on records reviewed and interviews conducted facility staff did not notify R1's responsible party of changes in R1's incontinence care needs that were observed, which poses a potential 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: 04/08/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/08/2024

LIC9099 (FAS) - (06/04)

Page: 3 of 5

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
12/13/2023 and conducted by Evaluator Angela Hood

COMPLAINT CONTROL NUMBER: 59-AS-20231213090351

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:	DATE:	04/08/2024
		UNANNOUNCED	TIME BEGAN:	11:45 AM
MET WITH:	Parveen Saroay, Executive Director		TIME COMPLETED:	04:15 PM

ALLEGATION(S):

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-Staff did not ensure a resident consumed an appropriate amount of liquid
-Staff unlawfully evicted resident
-Staff overcharged a resident for services not received

INVESTIGATION FINDINGS:

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Unfounded

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: 04/08/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/08/2024

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

Page: 4 of 5

Control Number 59-AS-20231213090351

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: 04/08/2024

NARRATIVE

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Allegation: Staff unlawfully evicted resident.
According to medical records and interviews with the ED and Resident Care Director (RCD), R1 was discharged from the hospital on 11/19/23 to a skilled nursing facility. Interview with RCD indicated that, when they assessed R1 at the skilled nursing facility, R1 was not at baseline and had a change in condition. According to R1’s Assessment conducted by RCD, dated 11/29/23, R1’s condition had changed in comparison to R1’s Assessment conducted on 9/29/23. Interviews with RCD and ED indicated that R1 would require a higher level of care and was not accepted back to the facility from the skilled nursing facility. ED stated that R1 was not evicted from the facility and no eviction notice was issued.

Allegation: Staff overcharged a resident for services not received.
According to facility invoices and R1’s transaction history, R1 was charged for 1 day in December 2023 pending R1’s property removal from the facility. Interviews with ED and the Business Office Manager indicated that R1 was not charged for services that were not received.

Based on interviews conducted and documentation reviewed, the above allegations are found to be UNFOUNDED. A finding that the allegation is unfounded means that the allegation is false, could not have happened, and/or is without a reasonable basis.

SUPERVISOR'S NAME: Maribeth Senty	TELEPHONE: (916) 214-0485
LICENSING EVALUATOR NAME: Angela Hood	TELEPHONE: 650-676-0390
LICENSING EVALUATOR SIGNATURE:	DATE: 04/08/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/08/2024

LIC9099 (FAS) - (06/04)

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