342700333-12-4-2024-59-AS-AHOD-DBMVMK-20241204153341

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 342700333
Report Date: 12/04/2024
Date Signed: 12/04/2024 03:34:38 PM

Document Has Been Signed on 12/04/2024 03:34 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT

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
ADMINISTRATOR/ DIRECTOR:	SAROAY, PARVEEN		FACILITY TYPE:	740
ADDRESS:	8845 FAIR OAKS BLVD		TELEPHONE:	(916) 944-2077
CITY:	CARMICHAEL	STATE: CA	ZIP CODE:	95608
CAPACITY: 106	TOTAL ENROLLED CHILDREN: 0	CENSUS: 104	DATE:	12/04/2024
TYPE OF VISIT:	Case Management - Other	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	02:30 PM
MET WITH:	Parveen Saroay, Executive Director and Kirt Hamburg, Licensee		TIME VISIT/ INSPECTION COMPLETED:	03:40 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analysts (LPAs) Angela Hood, Michael Hood, and Cassie Mikkelson arrived at the facility on December 4, 2024 for an unannounced Case Management visit. LPAs met with the Executive Director, Parveen Saroay, and the Licensee, Kirt Hamburg, to follow up on substantiated findings from a complaint investigation. On February 12, 2024, the Department concluded a complaint investigation which alleged the following: Facility did not seek timely medical treatment resulting in resident (R1) being hospitalized, and staff neglected to provide care to R1. The licensee was cited for California Code of Regulations (CCR) Section 87465(a)(1) Incidental Medical and Dental Care - Licensee shall arrange, or assist in arranging, for medical and dental care appropriate to the conditions and needs of residents. The licensee was also cited for CCR Section 87464(f)(1) Basic Services - Shall at a minimum include care and supervision. At the time of the complaint visit on February 12, 2024, an immediate civil penalty of $500 was issued and the licensee was informed that an additional civil penalty might be assessed based on Health and Safety Code Section 1569.49. The Department has concluded an analysis and has determined that a civil penalty is warranted for serious bodily injury. The Welfare and Institutions Code Section 15610.67 defines serious bodily injury as “an injury involving extreme physical pain, substantial risk of death, or protracted loss or impairment of function of a bodily member, organ, or of mental faculty, or requiring medical intervention, including, but not limited to, hospitalization, surgery, or physical rehabilitation.” This is evidenced by the facility not seeking timely *********************************************Continued on LIC809-C****************************************************

Maribeth Senty	TELEPHONE: (916) 214-0485
Angela Hood	TELEPHONE: 650-676-0390
	DATE: 12/04/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/04/2024

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

LIC809 (FAS) - (06/04)

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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 12/04/2024

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medical attention for R1, which resulted in R1’s diagnosis of severe sepsis secondary to pseudomonas bacteremia, acute kidney injury, tear to the urethral meatus and subsequent hospitalization.

Today, December 4, 2024, the Department will be issuing a civil penalty per Health and Safety Code Section 1569.49 for a violation that the Department constitutes as a serious bodily injury in the amount of $10,000. However, since an immediate civil penalty of $500 was previously issued on February 12, 2024, the amount of the civil penalty issued today will be $9,500.

A copy of the LIC421D was provided and originals were signed.

Exit interview conducted. A copy of the report was issued. Appeal rights provided. The signature on this report acknowledges receipt of the appeal rights, found on page two of LIC421D.

SUPERVISOR'S NAME: Maribeth Senty	TELEPHONE: (916) 214-0485
LICENSING EVALUATOR NAME: Angela Hood	TELEPHONE: 650-676-0390
LICENSING EVALUATOR SIGNATURE:	DATE: 12/04/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/04/2024

LIC809 (FAS) - (06/04)

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