345002797-8-29-2023-25-AS-KHOS-CVTKN5-20230919080235

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 345002797
Report Date: 08/29/2023
Date Signed: 08/29/2023 05:05:30 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
12/19/2022 and conducted by Evaluator Michael Hood

COMPLAINT CONTROL NUMBER: 25-AS-20221219130654

FACILITY NAME:	OAKMONT OF FAIR OAKS		FACILITY NUMBER:	345002797
ADMINISTRATOR:	POUYA ANSARI		FACILITY TYPE:	740
ADDRESS:	8484 MADISON AVE.		TELEPHONE:	(916) 633-1001
CITY:	FAIR OAKS	STATE: CA	ZIP CODE:	95628
CAPACITY:	128	CENSUS: 76	DATE:	08/29/2023
		UNANNOUNCED	TIME BEGAN:	12:30 PM
MET WITH:	Pouya Ansari, Executive Director		TIME COMPLETED:	02:00 PM

ALLEGATION(S):

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Residents are not given showers

Staff are not dispensing medications to residents

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Michael Hood arrived at the facility and met with Executive Director (ED), Pouya Ansari, to deliver findings into the complaint allegations listed above.

During the investigation, the Department conducted interviews, conducted a medication count, and reviewed documentation pertinent to the investigation.

The results of the investigation are as follows:

** Report continued on 9099-C **

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Anthony Perez	TELEPHONE: (323) 485-4915
LICENSING EVALUATOR NAME: Michael Hood	TELEPHONE: (916) 531-7341
LICENSING EVALUATOR SIGNATURE:	DATE: 08/29/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/29/2023

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 3

Control Number 25-AS-20221219130654

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: OAKMONT OF FAIR OAKS	FACILITY NUMBER: 345002797
	VISIT DATE: 08/29/2023

NARRATIVE

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Multiple relevant parties reported to the Department varying accounts of medication mismanagement by facility staff. LPA reviewed an internal document indicating that, on 1/1/2023 during a medication audit, it was found that a medication that was supposed to be given to a resident was not in the medication bin. Through more investigation, it was determined that the medication was reviewed and approved by Memory Care Director (MCD), Belinda Prunty, and listed to be “injected” even though the facility does not have injectable medication that they can administer. It was documented that MCD did not check to see if medication was at the facility and records indicated that medication had been marked as “given” by other med-techs.

During a visit conducted on 5/17/2023, LPAs Michael Hood and Angela Hood conducted a medication count for residents R1 and R2, comparing each resident’s Centrally Stored Medication Form (CSM) with medications centrally stored for the resident. LPAs observed three (3) medications for R2 that were off count in relation to what was documented. All three medications that were off count were over the amount documented. Facility was able to account for 1 day (4/29/2023) in which R2 was out of the facility, but no other refusals were documented that could account for the amount over what was documented. Due to facility receiving a citation regarding the same violation in a separate inspection conducted on 8/29/2023, no additional citations will be issued regarding allegation.

Multiple relevant parties reported to the Department that facility staff are not assisting residents with bathing. Interview with resident (R3) indicated that they went 5 to 6 weeks without a shower when they were requesting to have a shower. Resident Assessments for R3 dated 9/19/2022, 10/2/2022, 11/20/2022, and 4/13/2023 all indicated that R3 requires hands-on assistance for all showering/bathing needs 1 to 2 times a week.

** Report continued on 9099-C **

SUPERVISOR'S NAME: Anthony Perez	TELEPHONE: (323) 485-4915
LICENSING EVALUATOR NAME: Michael Hood	TELEPHONE: (916) 531-7341
LICENSING EVALUATOR SIGNATURE:	DATE: 08/29/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/29/2023

LIC9099 (FAS) - (06/04)

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Control Number 25-AS-20221219130654

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: OAKMONT OF FAIR OAKS	FACILITY NUMBER: 345002797
	VISIT DATE: 08/29/2023

NARRATIVE

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Interview with ED indicated that the facility required R3 to obtain a shower chair due to 2 person assist transfers no longer being safe for resident regarding showers. ED stated that R3 went without a shower for 30 days before obtaining a shower chair that R3 did not find comfortable, and another 30 days without a shower to obtain a different shower chair that worked for R3. During this time, R3 was obtaining bed baths from staff. ED stated that R3 was admitted with a hoyer lift to assist with transfers, but R3 refused to use the hoyer lift due to it being uncomfortable for resident. ED stated that R3 personally made the order for the shower chair and was not provided by the facility. Resident Assessments dated 9/19/2022, 10/2/2022, and 11/20/2022 for R3 indicated that resident required a two-person assist with the use of a mechanical lift. Resident Assessment dated 4/13/2023 for R3 indicated that R3 “requires two-person physical assistance with transfers.”

LPA reviewed R3's Physician's Report for RCFE LIC 602A dated 8/8/2022 and observed R3 was in need of assistance with bathing. LPA reviewed R3's Preplacement Appraisal Information (LIC 603) and observed R3 needs services for bathing. Resident Assessments for R3 dated 9/19/2022, 10/2/2022, 11/20/2022, and 4/13/2023 all indicated that R3 requires hands-on assistance for all showering/bathing needs 1 to 2 times a week. LPA reviewed the facility’s shift notes from April 2023 to August 2023 and Staff Assignments by Month by Unit for R3 from May 2023 to August 2023. LPA observed only 1 bed bath documented for 6/1/2023 for the month of June 2023. All other entries for June 2023 were blank and not documented as given. Bed baths and showers for R3 were documented inconsistently for the months of April 2023 and May 2023, with some weeks not having any bed baths or showers documented. ED was unable to provide any additional documentation regarding R3's bathing. Due to facility receiving a citation regarding the same violation in a separate inspection conducted on 8/29/2023, no additional citations will be issued regarding allegation.

Based on interviews conducted, a medication count, 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, deficiencies were cited during a separate inspection conducted on 8/29/2023 regarding the same violations.

Exit interview was conducted with ED. A copy of this report and appeal rights were provided. ED's signature on these forms acknowledges receipt of these documents.

SUPERVISOR'S NAME: Anthony Perez	TELEPHONE: (323) 485-4915
LICENSING EVALUATOR NAME: Michael Hood	TELEPHONE: (916) 531-7341
LICENSING EVALUATOR SIGNATURE:	DATE: 08/29/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/29/2023

LIC9099 (FAS) - (06/04)

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