342700938-9-16-2021-25-AS-MSEY-C6XP8Z-20210917110621

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 342700938
Report Date: 09/16/2021
Date Signed: 09/16/2021 03:46:20 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
04/23/2021 and conducted by Evaluator Angela Hood

COMPLAINT CONTROL NUMBER: 25-AS-20210423161250

FACILITY NAME:	FAIR OAKS VILLA		FACILITY NUMBER:	342700938
ADMINISTRATOR:	FOGGY, BRUCE		FACILITY TYPE:	740
ADDRESS:	8781 PHOENIX AVE.		TELEPHONE:	(916) 514-9421
CITY:	FAIR OAKS	STATE: CA	ZIP CODE:	95628
CAPACITY:	6	CENSUS: 5	DATE:	09/16/2021
		UNANNOUNCED	TIME BEGAN:	03:20 PM
MET WITH:	Maria Williams, Administrator		TIME COMPLETED:	03:45 PM

ALLEGATION(S):

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-Facility did not adhere to admission agreement.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Angela Hood arrived at the care home today and met with the Administrator, Maria Williams, to deliver findings into the allegation of facility did not adhere to admission agreement. LPA wore an N95 mask and was screened upon entry in the care home. All staff wore masks in the care home. There are no COVID positive cases at the facility.

Facility did not adhere to admission agreement
According to interviews with the Administrators, Bruce Foggy and Maria Williams, resident (R1’s) responsible party did not provide a 30-day written notice to the facility prior to R1 moving out of the facility. R1’s Admission Agreement signed on 12/18/2020 indicates “refunds will only be granted if a 30-day written notice was given to the licensee, prior to the resident’s departure from the facility”. The facility provided an invoice dated 3/4/21, which indicates R1’s responsible party was billed $816.66 for 3/1/21-3/7/21. The facility did

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Unfounded

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: 09/16/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/16/2021

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

LIC9099 (FAS) - (06/04)

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Control Number 25-AS-20210423161250

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 VILLA	FACILITY NUMBER: 342700938
	VISIT DATE: 09/16/2021

NARRATIVE

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not charge R1 for the full month of March’s rent, which is $3,500 and, according to the Admission Agreement, would only provide refunds if a 30-day written notice was provided to the facility.

Based on interviews conducted and records reviewed, the above allegations are found to be UNFOUNDED. A finding that the allegations are unfounded means that the allegations are false, could not have happened, and/or is without a reasonable basis. Exit interview conducted.

SUPERVISOR'S NAME: Maribeth Senty	TELEPHONE: (916) 214-0485
LICENSING EVALUATOR NAME: Angela Hood	TELEPHONE: 650-676-0390
LICENSING EVALUATOR SIGNATURE:	DATE: 09/16/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/16/2021

LIC9099 (FAS) - (06/04)

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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
04/23/2021 and conducted by Evaluator Angela Hood

COMPLAINT CONTROL NUMBER: 25-AS-20210423161250

FACILITY NAME:	FAIR OAKS VILLA		FACILITY NUMBER:	342700938
ADMINISTRATOR:	FOGGY, BRUCE		FACILITY TYPE:	740
ADDRESS:	8781 PHOENIX AVE.		TELEPHONE:	(916) 514-9421
CITY:	FAIR OAKS	STATE: CA	ZIP CODE:	95628
CAPACITY:	6	CENSUS: 5	DATE:	09/16/2021
		UNANNOUNCED	TIME BEGAN:	03:20 PM
MET WITH:	Maria Williams, Administrator		TIME COMPLETED:	03:45 PM

ALLEGATION(S):

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-Open door to facility left unattended.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Angela Hood arrived at the care home today and met with the Administrator, Maria Williams, to deliver findings into the allegation of an open door to facility was left unattended. LPA wore an N95 mask and was screened upon entry in the care home. All staff wore masks in the care home. There are no COVID positive cases at the facility.

Open door to facility left unattended.
During the course of the investigation, LPA conducted interviews. According to interviews with the Administrators, Bruce Foggy and Maria Williams, and staff (S1), the facility's exterior doors have never been left open and unattended. Information provided in interviews contradict information obtained from the relevant party. LPA conducted visits at the facility on 4/30/21 and 8/12/21 and did not observe the front door of the facility to be left open or unattended.

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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: 09/16/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/16/2021

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

LIC9099 (FAS) - (06/04)

Page: 3 of 4

Control Number 25-AS-20210423161250

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 VILLA	FACILITY NUMBER: 342700938
	VISIT DATE: 09/16/2021

NARRATIVE

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Additional concerns in complaint were addressed in a case management deficiencies visit conducted on 9/16/21.

Based on interviews conducted and observation, 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 allegation is UNSUBSTANTIATED. No deficiencies are being cited during this visit. Exit interview conducted.

SUPERVISOR'S NAME: Maribeth Senty	TELEPHONE: (916) 214-0485
LICENSING EVALUATOR NAME: Angela Hood	TELEPHONE: 650-676-0390
LICENSING EVALUATOR SIGNATURE:	DATE: 09/16/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/16/2021

LIC9099 (FAS) - (06/04)

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