345002797-8-29-2023-59-AS-MSEY-CVZN7L-20230925101252

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 345002797
Report Date: 08/29/2023
Date Signed: 08/29/2023 05:30:23 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
03/09/2023 and conducted by Evaluator Michael Hood

COMPLAINT CONTROL NUMBER: 59-AS-20230309134714

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:	02:00 PM
MET WITH:	Pouya Ansari, Executive Director		TIME COMPLETED:	03:30 PM

ALLEGATION(S):

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Staff are mismanaging medications

Staff are not assisting residents with incontinence care

Staff are not assisting residents with bathing

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)

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Control Number 59-AS-20230309134714

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 R2 and R3, 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 do not provide assistance with incontinence care and/or bathing. Interview with resident (R1) indicated that they do not receive assistance with incontinence care and they went 5 to 6 weeks without a shower when they were requesting to have a shower. R1 stated they were refused both due to being required to use a shower chair. Interview with ED indicated that the facility required R1 to obtain a shower chair due to 2 person assist transfers no longer being safe for resident. ED stated that R1 personally made the order for the shower chair and shower chair was not provided by the facility. ED stated that it took 30 days to obtain the first shower chair, in which resident refused to use due to being uncomfortable, and another 30 days to obtain a second shower chair that the resident was able to use. ED stated that R1 was originally admitted with the use of a hoyer lift, but R1 refused to use hoyer lift after admission due to being uncomfortable for resident.

** 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 59-AS-20230309134714

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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Resident Assessments dated 9/19/2022, 10/2/2022, and 11/20/2022 for R1 indicated that resident required a two-person assist with the use of a mechanical lift. Resident Assessment dated 4/13/2023 for R1 indicated that R1 “requires two-person physical assistance with transfers.”

LPA reviewed R1's Physician's Report for RCFE LIC 602A dated 8/8/2022 and observed R1 was in need of assistance with toileting and bathing. LPA reviewed R1's Preplacement Appraisal Information (LIC 603) and observed R1 is "unable to transfer unassisted" regarding toileting and needs services for bathing. LPA reviewed R1's Resident Assessments dated 9/19/2022, 10/2/2022, and 11/20/2022 indicating that R1 "requires stand-by assistance for toileting," and 4/13/2023 indicating that R1 "requires hands-on assistance with incontinence; gathering incontinence supplies, hygiene, and/or changing linen." Resident Assessments for R1 dated 9/19/2022, 10/2/2022, 11/20/2022, and 4/13/2023 all indicated that R1 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 R1 from May 2023 to August 2023. LPA observed only the morning of 6/1/2023 documented as having R1 receiving incontinence care for the month of June 2023. LPA also 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 care given. Bed baths and showers for R1 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 R1's incontinence care or bathing, including possible refusals.

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 are being cited on the attached 9099-D page.

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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Control Number 59-AS-20230309134714

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
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 08/29/2023

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Request Denied Type B 09/13/2023 Section Cited CCR 87468.1(a)(2)	1 2 3 4 5 6 7	87468.1 Personal Rights of Residents in All Facilities (a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (2) To be accorded safe, healthful and comfortable accommodations, furnishings and equipment. This requirement is not met as evidenced by:	1 2 3 4 5 6 7	Facility will complete a statement of understanding regarding regulation 87468.1. Facility will submit statement to LPA by POC due date of 9/13/23.
	8 9 10 11 12 13 14	Based on interviews conducted and records reviewed, the facility did not ensure resident R1 received a shower chair timely to assist with providing incontinence care and shower assistance, which poses a potential health, safety, and personal rights risk to the residents in care.	8 9 10 11 12 13 14
Request Denied Type B 09/13/2023 Section Cited CCR 87464(f)(1)	1 2 3 4 5 6 7	87464 Basic Services (f) Basic services shall at a minimum include: (1) Care and supervision as defined in Section 87101(c)(3) and Health and Safety Code section 1569.2(c). This requirement is not met as evidenced by:	1 2 3 4 5 6 7	Facility will conduct in-service training for staff regarding basic services and documentation. Facility will submit to LPA information regarding in-service training, including time and date of in-service and training material, by POC due date of 9/13/23.
	8 9 10 11 12 13 14	Based on interviews conducted and records reviewed, the facility did not ensure resident R1 was receiving incontience care and shower assistance, which poses a potential health, safety, and personal rights risk to the residents in care.	8 9 10 11 12 13 14

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: 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 appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/29/2023

LIC9099 (FAS) - (06/04)

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