342700333-9-3-2021-25-AS-MSEY-C6HSC5-20210903134458

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 342700333
Report Date: 09/03/2021
Date Signed: 09/03/2021 09:53:47 AM

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
07/30/2021 and conducted by Evaluator Melana Llopis

PUBLIC

COMPLAINT CONTROL NUMBER: 25-AS-20210730160136

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: 81	DATE:	09/03/2021
		UNANNOUNCED	TIME BEGAN:	08:30 AM
MET WITH:	Resident Care Coordinator, Angela Price		TIME COMPLETED:	10:00 AM

ALLEGATION(S):

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Staff mismanaged resident's COVID-19 vaccine

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Melana Llopis arrived at the facility unannounced on 09/03/2021 to deliver findings for a complaint the Department received on 07/30/2021. LPA met with Resident Care Coordinator, Angela Price and explained the purpose of the visit.

Prior to visit, LPA completed required COVID-19 testing protocols and a daily self-screening questionnaire for symptoms of COVID-19 infection to affirm no COVID-19 related symptoms, and contacted facility and completed a facility risk assessment. LPA ensured they applied hand sanitizer before entering the facility and the following Personal Protective Equipment (PPE) was worn: surgical mask. Additionally, LPA utilized facility's self screening sign-in sheet upon entering the facility.

Throughout the course of the investigation, LPA conducted multiple interviews and reviewed documentation pertinant to the allegation listed above.
Results are as follows:
***Continuation on LIC9099-C***

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Maribeth Senty	TELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Melana Llopis	TELEPHONE: 510-298-7052
LICENSING EVALUATOR SIGNATURE:	DATE: 09/03/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/03/2021

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 25-AS-20210730160136

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: 09/03/2021

NARRATIVE

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Allegation: Staff mismanaged resident's COVID-19 vaccine

Complaint alleged the facility mismanaged resident (R1)'s COVID-19 vaccine and accidentally provided R1 with two (2) differing vaccinations, which resulted in R1 having three (3) vaccinations total. On 08/04/2021, LPA Llopis conducted an initial on-site visit and spoke with the Administrator, three (3) staff and resident (R1). Administrator confirmed that the facility lost documentation of R1's first vaccination form. During initial visit, LPA reviewed resident records for R1 and found the following: R1 was provided their first vaccine dosage on 1/28/2021. R1's second dosage was provided on 2/21/2021. Vaccine cards indicate R1's first vaccination was Moderna, while the second vaccine was Pfizer. The third vaccine was provided on 03/14/2021.

Due to the above information, a deficiency is being cited and the allegation is being SUBSTANTIATED, meaning that the allegation is valid because the preponderance of the evidence standard has been met.

Deficiency cited can be found on LIC9099-D per California Code of Regulations, Title 22.

Exit interview conducted, copy of report and appeal rights provided.

SUPERVISOR'S NAME: Maribeth Senty	TELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Melana Llopis	TELEPHONE: 510-298-7052
LICENSING EVALUATOR SIGNATURE:	DATE: 09/03/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/03/2021

LIC9099 (FAS) - (06/04)

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Control Number 25-AS-20210730160136

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: 09/03/2021

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 09/04/2021 Section Cited CCR 87465(a)(5)	1 2 3 4 5 6 7	87465 Incidental Medical and Dental Care: (a) A plan for incidental medical and dental care shall be developed by each facility. The plan shall encourage routine medical and dental care and provide for assistance in obtaining such care, by compliance with the following:	1 2 3 4 5 6 7	Licensee understands the regulation cited during today's visit. Licensee agrees to create and submit to CCL their updated plan for documenting and keeping records for each resident's vaccination card and vaccine status to ensure residents' vaccines are not mismanaged. Licensee shall submit plan to CCL by POC date provided.
	8 9 10 11 12 13 14	5) The licensee shall assist residents with self administered medications as needed. This requirement was not met as evidenced by: Based on interviews and records reviewed the Licensee mismanaged R1's COVID-19 vaccinations and did not ensure R1 was provided the correct second	8 9 10 11 12 13 14	vaccine dosage which resulted in an immediate health, safety and personal rights risk to resident in care.
	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) 263-4813
LICENSING EVALUATOR NAME: Melana Llopis	TELEPHONE: 510-298-7052
LICENSING EVALUATOR SIGNATURE:	DATE: 09/03/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/03/2021

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
07/30/2021 and conducted by Evaluator Melana Llopis

PUBLIC

COMPLAINT CONTROL NUMBER: 25-AS-20210730160136

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: 81	DATE:	09/03/2021
		UNANNOUNCED	TIME BEGAN:	08:30 AM
MET WITH:			TIME COMPLETED:	10:00 AM

ALLEGATION(S):

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Insufficient staffing to meet the resident's needs

INVESTIGATION FINDINGS:

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Unfounded

Estimated Days of Completion:

SUPERVISOR'S NAME: Maribeth Senty	TELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Melana Llopis	TELEPHONE: 510-298-7052
LICENSING EVALUATOR SIGNATURE:	DATE: 09/03/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/03/2021

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 25-AS-20210730160136

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: 09/03/2021

NARRATIVE

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Allegation: Insufficient staffing to meet the resident's needs

Complaint alleged the facility does not have enough staff to meet resident (R1)'s needs. On 08/04/2021, LPA conducted an initial on-site visit and spoke with R1 and three (3) staff. Interview with R1 indicated, R1 is satisfied with their care, is doing well in the community and receives assistance from staff as needed.
Interviews with three (3) of three (3) staff stated they believe there are enough staff to care for R1's needs. On 08/04/2021, LPA reviewed R1's Needs and Service plan and Activities of Daily Living (ADL) charts for the past month. Records reviewed indicate R1 was provided care as needed. No further evidence was provided.

Based on the information above, LPA finds the allegation, Insufficient staffing to meet the resident's needs to be UNFOUNDED, meaning that the allegation was false, could not have happened and/or is without a reasonable basis.

Exit interview conducted, copy of report provided.

SUPERVISOR'S NAME: Maribeth Senty	TELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Melana Llopis	TELEPHONE: 510-298-7052
LICENSING EVALUATOR SIGNATURE:	DATE: 09/03/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/03/2021

LIC9099 (FAS) - (06/04)

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