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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 342700333
Report Date: 04/18/2021
Date Signed: 04/18/2021 12:20:58 PM



STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 520 COHASSET RD., STE. 170
CHICO, CA 95926
This is an official report of an unannounced visit/investigation of a complaint received in our office on
09/28/2020 and conducted by Evaluator Michael Reber
COMPLAINT CONTROL NUMBER: 27-AS-20200928160538
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: DATE:
04/18/2021
UNANNOUNCEDTIME BEGAN:
11:45 AM
MET WITH:Manisha MitranTIME COMPLETED:
12:30 PM
ALLEGATION(S):
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 - Residents hit by another resident while in care resulting in an injury(ies)
INVESTIGATION FINDINGS:
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Analyst Mike Reber arrived at the facility today, 4/18/21, and met wiith Manisha Mitran, to deliver investigation findings into the allegation that a resident hit another resident in care resulting in an injury. During the course of the investigation, this analyst conducted interviews and obtained/reviewed documentation pertinent to the investigation.

Upon entering the facility, analyst spoke with staff to pre-screen that the facility is COVID free. Analyst also self-screened for having no known symptoms or exposure. Analyst followed facility's screening, wore an N-95 respirator and maintained distance during the visit.


**********************************Report continued on LIC 9099C********************************
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Alycia BerrymanTELEPHONE: (916) 263-4700
LICENSING EVALUATOR NAME: Michael ReberTELEPHONE: (916) 263-4700
LICENSING EVALUATOR SIGNATURE:

DATE: 04/18/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/18/2021
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 27-AS-20200928160538
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 520 COHASSET RD., STE. 170
CHICO, CA 95926
FACILITY NAME: FAIR OAKS ESTATES INC
FACILITY NUMBER: 342700333
VISIT DATE: 04/18/2021
NARRATIVE
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A review of documents received, and interviews conducted reveal that resident (R1) had been experiencing episodes of agitation and aggression to other residents and staff in the facility. An incident report obtained states that on the evening of 9/20/20, R1 was observed chasing a staff member while attempting to stab the staff with a butter knife. R1 was sent to the hospital for further evaluation. Another incident report obtained indicates that on the afternoon of 9/23/20, R1 went into R2 room and grabbed R2 by the neck and choked her. R1 also grabbed R2 by the arm causing a bruise and a scratch resulting in staff applying first aid to R2 arm. Another incident report on 9/26/2020 and documentation in a staff communication log indicates that R1 attacked another resident and two staff members and was sent to the hospital again.

Interviews with 3 staff revealed that R1 had been sent to the hospital several times and returned but the medication adjustments were not effective in dealing with R1 aggressive behaviors. Analyst reviewed R1 needs and services plan and observed that the facility failed to put safeguards in place to protect R2 and other residents knowing that R1 was displaying behavior that put the health and safety of others at risk.

Based on information interviews conducted and records reviewed, this analyst finds the allegation to be SUBSTANTIATED - a finding that means that the allegation is valid because the preponderance of the evidence standard has been met.

Per California Code of Regulations, Title 22 Division 6, Chapter 8, deficiencies are being cited on the attached 9099-D.

Exit interview conducted. Copy of report and appeal rights provided to staff.

SUPERVISOR'S NAME: Alycia BerrymanTELEPHONE: (916) 263-4700
LICENSING EVALUATOR NAME: Michael ReberTELEPHONE: (916) 263-4700
LICENSING EVALUATOR SIGNATURE:

DATE: 04/18/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/18/2021
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 27-AS-20200928160538
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 520 COHASSET RD., STE. 170
CHICO, CA 95926

FACILITY NAME: FAIR OAKS ESTATES INC
FACILITY NUMBER: 342700333
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/18/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
04/30/2021
Section Cited
CCR
87411(a)
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Personnel Requirements - General

Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs.
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R1 no longer resides in the facility and does not present an immediate risk to other residents in care. To protect the health and safety of residents, administrator shall sign a statement of understanding by POC due date of 4/30/21 that sufficient staffing will be present at all times based on the current needs of all residents in care.
Type B
04/30/2021
Section Cited
CCR
87405(d)(1)
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Administrator Qualifications

The administrator shall have the qualifications specified in Sections 87405(d)(1) through (7).

(1) Knowledge of the requirements for providing care and supervision appropriate to the residents.
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Administrator shall complete a continuing education class on the topic of observation of residents/appraisals and reappraisals to recognize changes in a resident condition and implementing interventions to ensure the safety of the residents. Submit details of training to LPA by POC due date of 4/30/21, and submit certificate of training to LPA when completed.
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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: Alycia BerrymanTELEPHONE: (916) 263-4700
LICENSING EVALUATOR NAME: Michael ReberTELEPHONE: (916) 263-4700
LICENSING EVALUATOR SIGNATURE:

DATE: 04/18/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/18/2021
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
CCLD Regional Office, 520 COHASSET RD., STE. 170
CHICO, CA 95926
This is an official report of an unannounced visit/investigation of a complaint received in our office on
09/28/2020 and conducted by Evaluator Michael Reber
COMPLAINT CONTROL NUMBER: 27-AS-20200928160538

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: DATE:
04/18/2021
UNANNOUNCEDTIME BEGAN:
11:45 AM
MET WITH:Manisha MitranTIME COMPLETED:
12:30 PM
ALLEGATION(S):
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 - Staff not notifying resident’s authorized representative of incident involving resident
INVESTIGATION FINDINGS:
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Analyst Mike Reber arrived at the facility today, 4/18/21, and met wiith Manisha Mitran, to deliver investigation findings into the allegation that staff are not notifying resident's authorized representative of incident involving resident. During the course of the investigation, this analyst conducted interviews and obtained/reviewed documentation pertinent to the investigation.

Upon entering the facility, analyst spoke with staff to pre-screen that the facility is COVID free. Analyst also self-screened for having no known symptoms or exposure. Analyst followed facility's screening, wore an N-95 respirator and maintained distance during the visit.


**********************************Report continued on LIC 9099C********************************
Unfounded
Estimated Days of Completion:
SUPERVISOR'S NAME: Alycia BerrymanTELEPHONE: (916) 263-4700
LICENSING EVALUATOR NAME: Michael ReberTELEPHONE: (916) 263-4700
LICENSING EVALUATOR SIGNATURE:

DATE: 04/18/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/18/2021
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 27-AS-20200928160538
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 520 COHASSET RD., STE. 170
CHICO, CA 95926
FACILITY NAME: FAIR OAKS ESTATES INC
FACILITY NUMBER: 342700333
VISIT DATE: 04/18/2021
NARRATIVE
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A review of R2 admission agreement indicates that R2 in her own responsible party. Since the facility admission agreement does not list the reporting party as the responsible party, the facility is not required to contact the RP.

Based on information obtained, Analyst finds the allegations to be UNFOUNDED – a finding meaning that the allegation was false, could not have happened and/or is without a reasonable basis.

As a result of this investigation, no deficiencies were cited, per Title 22 Regulations, Division 6.

Exit interview conducted. Copy of report left with staff.

SUPERVISOR'S NAME: Alycia BerrymanTELEPHONE: (916) 263-4700
LICENSING EVALUATOR NAME: Michael ReberTELEPHONE: (916) 263-4700
LICENSING EVALUATOR SIGNATURE:

DATE: 04/18/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/18/2021
LIC9099 (FAS) - (06/04)
Page: 5 of 5