342700333-12-11-2024-59-AS-MSEY-DC4PAD-20241219100832

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 342700333
Report Date: 12/11/2024
Date Signed: 12/11/2024 04:35:41 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
09/03/2024 and conducted by Evaluator Angela Hood

COMPLAINT CONTROL NUMBER: 59-AS-20240903233231

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: 102	DATE:	12/11/2024
		UNANNOUNCED	TIME BEGAN:	11:50 AM
MET WITH:	Parveen Saroay, Executive Director		TIME COMPLETED:	04:50 PM

ALLEGATION(S):

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-Facility did not prevent a resident in care from eloping.
-Staff did not keep facility free of insects.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Angela Hood arrived at the care home today, 12/11/24, and met with the Executive Director, Parveen Saroay, to deliver complaint investigation findings regarding the above listed allegations.

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

Allegation: Facility did not prevent a resident in care from eloping.
On 3/4/24, resident (R1) left the facility to attend day program. R1 typically returns to the facility from day program in the afternoon or evening. On 3/5/24, at approximately 1:30pm, the Executive Director was notified by the Resident Care Director (RCD) that R1 was missing. RCD contacted the Sheriff’s Department and R1’s responsible parties. R1 was wearing a tracking device monitored by the responsible parties.
********************************************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: 12/11/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/11/2024

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-20240903233231

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: 12/11/2024

NARRATIVE

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R1 was found by responsible party and taken home with them. The facility reviewed their camera’s video footage from 3/4/24 and found that R1 had returned from day program at around 4:45pm and was AWOL at 5:15pm. R1 left the facility through the front door and, although the alarm was triggered, staff turned it off without checking outside for any residents. According to facility’s internal investigation, care staff did not investigate why R1 was still on a leave of absence in their system from attending day program. All staff who did not follow facility’s protocol received disciplinary actions. A training was conducted as well. R1 was sent to the hospital upon return to the facility. On 3/7/24, R1 returned to the care home and was moved to the memory care unit.

Allegation: Staff did not keep facility free of insects.
On 10/10/24, LPA toured the facility, observing two (2) shared bedrooms in assisted living and two (2) shared bedrooms in memory care. LPA checked four (4) beds in assisted living and four (4) bed in memory care and did not observe any bedbugs. All rooms appeared clean and in sanitary condition with no observation of insects. There were no observations of insects throughout the tour of the care home. Interviews with residents (R2, R3, R4, and R5) indicated that they have never observed insects or bed bugs in the care home. Interviews with the Floor Manager, RCD, and S1 indicated that they have never observed bedbugs in R1’s room. LPA obtained copies of the facility’s pest control services summary reports from June 2024-November 2024, which indicated that the facility receives monthly pest control services to the interior and exterior of the care home. The July 2024 pest control services summary report indicated that R1’s room had live bedbugs, which was treated. The following months, August 2024-November 2024, indicated that there were no longer any sightings of bedbugs in R1’s room. The facility is currently being treated monthly for pests and the bedbug issue in R1’s room has been resolved; thus, no citation is being issued regarding this allegation.

Based on observation, 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, a deficiency is being cited on the attached 9099-D page.

Exit interview conducted. A copy of the report and appeal rights provided.

SUPERVISOR'S NAME: Maribeth Senty	TELEPHONE: (916) 214-0485
LICENSING EVALUATOR NAME: Angela Hood	TELEPHONE: 650-676-0390
LICENSING EVALUATOR SIGNATURE:	DATE: 12/11/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/11/2024

LIC9099 (FAS) - (06/04)

Page: 2 of 5

Control Number 59-AS-20240903233231

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: 12/11/2024

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 12/12/2024 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 conduct an in-service training with all staff regarding missing residents/elopement indicating the date and time, as well as all participants to submit to LPA by the POC due date of 12/12/24. LPA extended due date to 12/13/24.
	8 9 10 11 12 13 14	Based on records reviewed and interviews conducted, the facility did not ensure that resident (R1) was properly supervised, resulting in AWOL, which poses an immediate health, safety, and personal rights risk to residents in care.	8 9 10 11 12 13 14
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

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: 12/11/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/11/2024

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
09/03/2024 and conducted by Evaluator Angela Hood

COMPLAINT CONTROL NUMBER: 59-AS-20240903233231

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: 102	DATE:	12/11/2024
		UNANNOUNCED	TIME BEGAN:	11:50 AM
MET WITH:	Parveen Saroay, Executive Director		TIME COMPLETED:	04:50 PM

ALLEGATION(S):

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-Resident sustained unexplained injuries while in care.
-Staff did not ensure resident's needs are being met.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Angela Hood arrived at the care home today, 12/11/24, and met with the Executive Director, Parveen Saroay, to deliver complaint investigation findings regarding the above listed allegations.

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

Allegation: Resident sustained unexplained injuries while in care.
Interviews with the Executive Director (ED), Resident Care Director (RCD), Floor Manager, and staff (S1) indicated that resident (R1) has not sustained any unexplained injuries while residing at the care home. RCD indicated that R1’s responsible party assists R1 with showering and noticed that R1 had some bruising on their arm. RCD indicated that they interviewed staff members in memory care. However, none
***********************************************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: 12/11/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/11/2024

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-20240903233231

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: 12/11/2024

NARRATIVE

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of the staff were aware of how the bruising formed. Interviews with ED, RCD, Floor Manager, and S1 indicated that R1 has aggressive behaviors. R1 attends a day program outside the facility as well. LPA reviewed all Unusual Incident/Injury Reports LIC624s regarding R1. There were no incidents reported regarding unexplained injuries sustained by R1.

Allegation: Staff did not ensure resident's needs are being met.
According to R1’s current care plan, dated 10/2/24, R1 requires assistance with medications, reminders dressing, a high level of staff supervision for behaviors, and incontinence care. The facility’s Service Checkoff List for the month of August 2024 indicated that R1 has been receiving all scheduled services for care assistance. R1’s Progress Notes, dated 8/15/24-10/19/24, indicated that there were several occasions that R1 refused to have staff assist with applying a physician’s ordered cream for a skin rash. According to Progress Notes and interviews with ED, RCD, Floor Manager, and S1, R1 would become aggressive with staff when attempting to assist with applying cream prescription. Progress Notes indicated that the facility had been in communication with R1’s physician and responsible parties regarding refusals. Interviews with ED and RCD indicated that R1 had been sent to the hospital several times due to aggressive behaviors and adjustments had been made to medications. Interviews with residents (R2, R3, R4, and R5) indicated that they feel that all their care needs are being met by the care home. LPA attempted to interview R1, who indicated that they were doing well and are treated well. LPA observed R1 who appeared to be well groomed and wearing clean clothing.

Based on observation, 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 violations 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: 12/11/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/11/2024

LIC9099 (FAS) - (06/04)

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