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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 342700333
Report Date: 04/18/2024
Date Signed: 04/18/2024 03:20:05 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
08/15/2023 and conducted by Evaluator Angela Hood
COMPLAINT CONTROL NUMBER: 59-AS-20230815094803
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: 102DATE:
04/18/2024
UNANNOUNCEDTIME BEGAN:
10:15 AM
MET WITH:Parveen Saroay, Executive DirectorTIME COMPLETED:
03:35 PM
ALLEGATION(S):
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-Resident sustained an unexplained fracture while in care.
-Resident was left on floor for an extended period of time.
-Staff do not communicate resident's incidents to responsible party.
-Facility floors are not clean and sanitized.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Angela Hood arrived unannounced at the care home today, 4/18/24, and met with the Executive Director (ED), Parveen Saroay, to deliver complaint investigation findings into the above stated allegations.

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

Allegation: Resident sustained an unexplained fracture while in care.
According to interviews with facility staff and documentation obtained, resident (R1) required assistance with all activities of daily living (ADLs). R1 resided in the memory care unit of the care home. R1 had no history of falls while residing at the facility. According to Unusual Incident/Injury Report and interviews conducted
***********************************************Continued on LIC9099-C************************************************
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Maribeth SentyTELEPHONE: (916) 214-0485
LICENSING EVALUATOR NAME: Angela HoodTELEPHONE: 650-676-0390
LICENSING EVALUATOR SIGNATURE:

DATE: 04/18/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/18/2024
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-20230815094803
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: 04/18/2024
NARRATIVE
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with staff, while R1 was receiving assistance with ADLs on 6/18/23, R1 gestured to staff of pain in their left side. Staff indicated that they did not observe any bruises or any other injuries. Staff indicated that they did not witness any incidents prior to R1 gesturing that they were experiencing pain. Unusual Incident/Injury Report and interviews with staff indicated that R1’s responsible party was notified regarding R1’s complaint of pain. Staff indicated that they informed R1’s responsible party that they would like to send R1 to the hospital to be evaluated. Staff indicated that R1’s responsible party instructed the facility that they would schedule an appointment with R1’s primary care physician (PCP). According to Unusual Incident/Injury Report and interviews conducted, R1 was seen by their PCP on 6/22/23 and R1 was discovered to have fractured ribs on their left side.

Medical records indicated that R1’s responsible party contacted the hospital, on 6/18/23, requesting a checkup for R1. R1 was taken to their scheduled appointment on 6/22/23. Medical Records indicated that R1 had complained of pain and no fall was reported. R1 was found to have minimally displaced left anterior lateral seventh, eighth, ninth, and tenth rib fractures.

Interviews with residents, who had recently sustained falls at the care home, indicated that staff go out of their way to ensure residents are given medical treatment, when needed. No residents had any complaints regarding staff and the care being provided.

Allegation: Resident was left on floor for an extended period of time.
Interviews with ED and multiple staff indicated that R1 was not a fall risk and had no incidents of falls while at the care home. Interviews indicated that R1 was good at walking. Interviews also indicated that R1 did not require any mobility devices. Progress notes dated 5/15/23-7/27/23 indicated on multiple entries that R1 was walking independently and there were no notations of R1 falling while residing at the care home. The facility did not have any incidents indicating R1 had any falls.

Allegation: Staff do not communicate resident's incidents to responsible party.
Interview with ED indicated that R1 only had one incident while residing at the care home, which occurred on 6/18/23. The 6/18/23 incident was regarding R1 gesturing to staff that they were experiencing pain in their left side. Unusual Incident/Injury Report indicated that staff contacted R1’s responsible party, as well as the responsible party would set up a doctor’s appointment for R1. Interview with S1 indicated that when R1 was
*************************************************Continued LIC9099-C******************************************************
SUPERVISOR'S NAME: Maribeth SentyTELEPHONE: (916) 214-0485
LICENSING EVALUATOR NAME: Angela HoodTELEPHONE: 650-676-0390
LICENSING EVALUATOR SIGNATURE:

DATE: 04/18/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/18/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 59-AS-20230815094803
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: 04/18/2024
NARRATIVE
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found, on 6/25/23, in R2’s room no injuries were observed or noted. S1 indicated that it did not appear that R1 had fallen and that they had one knee on the floor. S1 indicated that, if there was something unusual with a resident, they would contact the family and physician. Interviews with ED and S1 indicated that R1’s normal behavior was wandering into other residents’ rooms and that R1’s responsible party was aware of R1’s behaviors.

Allegation: Facility floors are not clean and sanitized.
On 8/15/23, 4/3/24, and 4/11/24, LPA observed the memory care unit of the facility. The memory care unit has hard floors, which appeared to be clean and sanitized during the visits. On 4/11/24, LPA conducted an annual inspection of the care home and toured the facility. During the visit, LPA observed staff cleaning the floors several times throughout the day and the floors appeared to be clean and sanitized.

Based on observations, interviews conducted, and documentation obtained, although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur. Therefore, the allegations are UNSUBSTANTIATED. No deficiencies are being cited.

Exit interview conducted. A copy of the report was provided.
SUPERVISOR'S NAME: Maribeth SentyTELEPHONE: (916) 214-0485
LICENSING EVALUATOR NAME: Angela HoodTELEPHONE: 650-676-0390
LICENSING EVALUATOR SIGNATURE:

DATE: 04/18/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/18/2024
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
08/15/2023 and conducted by Evaluator Angela Hood
COMPLAINT CONTROL NUMBER: 59-AS-20230815094803

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: 102DATE:
04/18/2024
UNANNOUNCEDTIME BEGAN:
10:15 AM
MET WITH:Parveen Saroay, Executive DirectorTIME COMPLETED:
03:35 PM
ALLEGATION(S):
1
2
3
4
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-Staff did not seek medical attention to resident in a timely manner.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Angela Hood arrived unannounced at the care home today, 4/18/24, and met with the Executive Director (ED), Parveen Saroay, to deliver complaint investigation findings into the above stated allegation.

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

Allegation: Staff did not seek medical attention to resident in a timely manner.
According to staff interviews and facility’s incident report, on 6/25/23, resident (R1) was heard “screaming” from another resident’s (R2) room. Staff found R1 in R2’s room kneeling on the floor. Staff examined R1 and no injuries were observed or reported. Staff escorted R1 out of R2’s room and reminded R1 not to go into other residents’ rooms. Interviews and records indicated that R1 and R2 resided in the memory care unit
*********************************************Continued on LIC9099-C*************************************************
Unfounded
Estimated Days of Completion:
SUPERVISOR'S NAME: Maribeth SentyTELEPHONE: (916) 214-0485
LICENSING EVALUATOR NAME: Angela HoodTELEPHONE: 650-676-0390
LICENSING EVALUATOR SIGNATURE:

DATE: 04/18/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/18/2024
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-20230815094803
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: 04/18/2024
NARRATIVE
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of the care home. According to interviews and documentation obtained by the Department, R1 did not have an altercation with R2 and did not require medical attention.

Interviews conducted with ED and staff (S1) indicated that R1 had a habit of wandering into other residents’ rooms frequently and required redirection. Interview with S1 indicated that they were present and witnessed R1 in R2’s room on 6/25/23. S1 indicated that R1 was not screaming in pain. S1 indicated that R1 was yelling at R2 and R2 was telling R1 to leave their room while holding R1’s hand. Interviews with ED and S1 indicated that R1 was frequently agitated. Progress Notes dated 5/15/23-7/27/23, indicated multiple instances of R1 expressing agitation and exhibiting wandering behaviors requiring redirection. Physician’s Report LIC602A dated 4/14/23 indicated that R1 has sundowning, wandering, and aggressive behaviors.

Based on interviews conducted and documentation reviewed, the above allegation is 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. No deficiencies are being cited.

Exit interview conducted. A copy of the report was provided.
SUPERVISOR'S NAME: Maribeth SentyTELEPHONE: (916) 214-0485
LICENSING EVALUATOR NAME: Angela HoodTELEPHONE: 650-676-0390
LICENSING EVALUATOR SIGNATURE:

DATE: 04/18/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/18/2024
LIC9099 (FAS) - (06/04)
Page: 5 of 5