342700333-10-24-2024-59-AS-MSEY-DASN3N-20241107090633

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 342700333
Report Date: 10/24/2024
Date Signed: 10/24/2024 03:17:34 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
08/13/2024 and conducted by Evaluator Angela Hood

COMPLAINT CONTROL NUMBER: 59-AS-20240813150626

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: 104	DATE:	10/24/2024
		UNANNOUNCED	TIME BEGAN:	12:45 PM
MET WITH:	Parveen Saroay, Executive Director		TIME COMPLETED:	03:40 PM

ALLEGATION(S):

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-Staff did not dispense medication to resident as prescribed.
-Staff did not provide resident with personal care supplies.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Angela Hood arrived at the care home today, 10/24/24, and met with the Executive Director, Parveen Saroay, to deliver complaint investigation findings into the above stated allegations.

During the course of the investigation, LPA conducted interivews, medication counts, 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: 10/24/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/24/2024

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-20240813150626

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: 10/24/2024

NARRATIVE

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Allegation: Staff did not dispense medication to resident as prescribed.
On 10/16/24 and 10/24/24, LPA conducted a medication count for residents (R6 & R7), comparing the residents’ medication lists on file with medication centrally stored for the residents. LPA did not observe any medication errors. Interviews with residents (R2, R3, R4, and R5) indicated that they receive all their medications as prescribed. LPA reviewed R1’s medication sheet for the dates that they resided at the care home. The medication sheet indicated that R1 received medication while at the care home. LPA was unable to complete a medication count for R1 as they no longer reside at the care home.

Allegation: Staff did not provide resident with personal care supplies.
Interview with Executive Director indicated that all residents receive a welcome packet with personal care supplies upon move in to the facility. Interviews with R2, R3, and R4 indicated that they received personal care supplies from the facility upon move in. Interviews with R2, R3, R4, and R5 indicated that they provide their own personal care supplies, however, the facility will provide supplies, if needed. Interview with R1 indicated that they did not receive a towel when requested. Interviews with the Resident Care Director and Memory Care Coordinator indicated that they never received a request for a towel from R1. Interviews with Resident Care Director and Resident Care Coordinator indicated that the facility has towels available to residents in care that they keep in the linen closet and laundry room. LPA observed the linen supply at the care home. Care home has an ample supply of linens to provide to residents in care.

Based on observation, interviews conducted, medication count, 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 Senty	TELEPHONE: (916) 214-0485
LICENSING EVALUATOR NAME: Angela Hood	TELEPHONE: 650-676-0390
LICENSING EVALUATOR SIGNATURE:	DATE: 10/24/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/24/2024

LIC9099 (FAS) - (06/04)

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