<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700601
Report Date: 08/30/2022
Date Signed: 08/30/2022 02:54:49 PM


Document Has Been Signed on 08/30/2022 02:54 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
CCLD Regional Office, 520 COHASSET RD., STE. 170
CHICO, CA 95926



FACILITY NAME:OAKMONT OF FAIR OAKSFACILITY NUMBER:
342700601
ADMINISTRATOR:CONDIE, NATHANFACILITY TYPE:
740
ADDRESS:8484 MADISON AVENUETELEPHONE:
(916) 633-1001
CITY:FAIR OAKSSTATE: CAZIP CODE:
95628
CAPACITY:0CENSUS: 82DATE:
08/30/2022
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
02:30 PM
MET WITH:Pouya Ansari, Administrator TIME COMPLETED:
03:00 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 Analyst (LPA) Sabrina Calzada arrived unannounced to issue a related deficiency to complaint findings issued on August 2, 2022. LPA met with Administrator, Pouya Ansari, and explained purpose of inspection. Prior to initiating today's inspection, LPA completed required COVID-19 testing protocols and completed a daily self-screening questionnaire for symptoms of COVID-19 infection to affirm no COVID-19 related symptoms. Additionally, LPA was screened per Covid-19 precautionary measures upon entering the community. LPA ensured she applied hand sanitizer before entering the facility and the following Personal Protective Equipment (PPE) was worn: surgical mask.

On August 2, 2022, the Department concluded a complaint investigation (#25-AS-20211104135340) which substantiated the allegation that facility staff did not follow physician’s order to change resident’s (R1) contact lenses. The facility was advised that the incident would be further reviewed by the Department to determine if a $500.00 civil penalty is warranted due to resident having vision worse than 20/400 due to contact lenses not being changed monthly.

The Department reviewed the letter dated August 17, 2020 from resident's optometrist stating that, during an eye exam in August 2020, resident had one contact lens missing and the other one was heavily stained with significant deposits and buildup, indicative that the lens was left in much longer than it should have been due to staff not following physician's orders to change the lenses monthly. The letter further states that resident's eyesight was worse than 20/400, which would significantly affect resident's daily functions.

The Department determined that based on the optometrist's letter, there is sufficient evidence to issue a $500 civil penalty to the facility pursuant to Health and Safety Code section 1569.49(c)(1) - a violation that resulted in the injury or illness of a resident.

Today, 8/30/2022, the Department is issuing a Civil Penalty in the amount of $500.

Exit interview was conducted with Administrator. A copy of this report and appeal rights were provided. The Administrator’s signature on these forms acknowledges receipt of these documents.
SUPERVISOR'S NAME: Maribeth SentyTELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Sabrina CalzadaTELEPHONE: (510) 829-2133
LICENSING EVALUATOR SIGNATURE:
DATE: 08/30/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/30/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2


Document Has Been Signed on 08/30/2022 02:54 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

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


FACILITY NAME: OAKMONT OF FAIR OAKS
FACILITY NUMBER: 342700601

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/30/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
09/14/2022
Section Cited

1
2
3
4
5
6
7
§1569.49 Civil penalties; regulations setting forth appeal procedures for deficiencies. (c) The department shall assess an immediate civil penalty of five hundred dollars ($500) per violation and one hundred dollars ($100) for each day the violation continues after citation for any of the following serious violations:
(1) Any violation that the department determines resulted in the injury or illness of a resident.

This requirement is not met as evidenced by:
8
9
10
11
12
13
14
Based on documentation reviewed and interviews conducted, the Licensee did not ensure that resident (R1) had his contact lenses changed monthly from February 2020 through August 2020, per physician's orders, which posed an immediatel health and safety risk to resident in care.
8
9
10
11
12
13
14
* A CIVIL PENALTY is also being issued today for $500.00 due to the resident sustaining an injury or illness.

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 SentyTELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Sabrina CalzadaTELEPHONE: (510) 829-2133
LICENSING EVALUATOR SIGNATURE:
DATE: 08/30/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/30/2022
LIC809 (FAS) - (06/04)
Page: 2 of 2