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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 345002797
Report Date: 01/31/2024
Date Signed: 01/31/2024 02:35:26 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
09/15/2023 and conducted by Evaluator Michael Hood
COMPLAINT CONTROL NUMBER: 59-AS-20230915101913
FACILITY NAME:OAKMONT OF FAIR OAKSFACILITY NUMBER:
345002797
ADMINISTRATOR:POUYA ANSARIFACILITY TYPE:
740
ADDRESS:8484 MADISON AVE.TELEPHONE:
(916) 633-1001
CITY:FAIR OAKSSTATE: CAZIP CODE:
95628
CAPACITY:128CENSUS: 76DATE:
01/31/2024
UNANNOUNCEDTIME BEGAN:
01:05 PM
MET WITH:Pouya Ansari, Executive DirectorTIME COMPLETED:
02:50 PM
ALLEGATION(S):
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Staff are not meeting a resident's oxygen needs while in care
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 allegation listed above.

During the investigation, the Department conducted inspections and interviews, and reviewed documentation pertinent to the investigation. The results of the investigation are as follows:

Interviews with multiple relevant parties indicated that resident (R1) is supposed to be wearing and using their oxygen whenever they are ambulating outside of their apartment.

** Report continued on 9099-C **
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Anthony PerezTELEPHONE: (323) 485-4915
LICENSING EVALUATOR NAME: Michael HoodTELEPHONE: (916) 531-7341
LICENSING EVALUATOR SIGNATURE:

DATE: 01/31/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/31/2024
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 59-AS-20230915101913
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: 01/31/2024
NARRATIVE
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Interview with staff (S1) indicated that R1 is not really using their oxygen and only uses it if staff observe R1 is out of breath. Interview with staff (S3) indicated that R1 uses oxygen only when they walk around the facility, but most of the time they don't use it and don't need it. Interview with staff (S4) indicated that they were told that R1 didn't need their oxygen and R1 only uses their oxygen sporadically when they are walking.

LPA reviewed R1's Physician's Report for RCFE (LIC 602A) dated 7/18/2023, which indicates that R1 has a diagnosis of Chronic Respiratory Failure and Hypoxia as of 5/2022. LPA reviewed Doctor's Order Sheet for R1's oxygen dated 10/20/2023, which states "PRN use of Oxygen when active or ambulating. Staff is to help patient with use of oxygen when needed."

During visit conducted on 1/10/2024, LPA observed R1 in the activity room without their oxygen with them. LPA observed R1's oxygen in their apartment while R1 was in the activity room and not in their apartment.

Based on interviews conducted, the preponderance of evidence standards have been met. Therefore, the above allegation is found to be SUBSTANTIATED. Per California Code of Regulations, Title 22, Division 6, Chapter 8, a deficiency is being cited on the attached 9099-D page.

Exit interview was conducted with ED. A copy of this report and appeal rights were provided. Signature on these forms acknowledges receipt of these documents.
SUPERVISOR'S NAME: Anthony PerezTELEPHONE: (323) 485-4915
LICENSING EVALUATOR NAME: Michael HoodTELEPHONE: (916) 531-7341
LICENSING EVALUATOR SIGNATURE:

DATE: 01/31/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/31/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 59-AS-20230915101913
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: 01/31/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
02/01/2024
Section Cited
CCR
87611(e)
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87611 General Requirements for Allowable Health Conditions (e) In addition to Sections 87465(a) and 87464(d) the licensee shall ensure that the resident is cared for in accordance with the physician's orders and that the resident's medical needs are met. This requirement is not met as evidenced by:
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Facility will ensure that R1 has their oxygen when active or ambulating in the facility. A training regarding use of oxygen will be completed for staff. ED will complete a statement of understanding regarding 87611.
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Based on interviews conducted, observations, and records reviewed, facility did not ensure that PRN order for R1's oxygen was followeed, which poses an immediate health, safety, and personal rights risk to the residents in care.
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Facility will submit statement of understanding, along with date and materials for staff training, to LPA by POC due date of 2/1/2024.
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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 PerezTELEPHONE: (323) 485-4915
LICENSING EVALUATOR NAME: Michael HoodTELEPHONE: (916) 531-7341
LICENSING EVALUATOR SIGNATURE:

DATE: 01/31/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/31/2024
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
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
09/15/2023 and conducted by Evaluator Michael Hood
COMPLAINT CONTROL NUMBER: 59-AS-20230915101913

FACILITY NAME:OAKMONT OF FAIR OAKSFACILITY NUMBER:
345002797
ADMINISTRATOR:POUYA ANSARIFACILITY TYPE:
740
ADDRESS:8484 MADISON AVE.TELEPHONE:
(916) 633-1001
CITY:FAIR OAKSSTATE: CAZIP CODE:
95628
CAPACITY:128CENSUS: 76DATE:
01/31/2024
UNANNOUNCEDTIME BEGAN:
01:05 PM
MET WITH:Pouya Ansari, Executive DirectorTIME COMPLETED:
02:50 PM
ALLEGATION(S):
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Staff provided a resident with a defective call button

Staff are not providing adequate care and supervision to a resident

Staff do not have planned activities for a resident
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 inspections and interviews, and reviewed documentation pertinent to the investigation. The results of the investigation are as follows:

Interviews with staff and multiple relevant parties indicated that resident (R1's) call button is operable, that calls are made to staff pagers, and response times may be delayed as R1 lives in Memory Care and calls are sent to Assisted Living staff. Interview with relevant party stated that R1's call button was tested and staff responded to R1's call button.

** Report continued on 9099-C **
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Anthony PerezTELEPHONE: (323) 485-4915
LICENSING EVALUATOR NAME: Michael HoodTELEPHONE: (916) 531-7341
LICENSING EVALUATOR SIGNATURE:

DATE: 01/31/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/31/2024
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 59-AS-20230915101913
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: 01/31/2024
NARRATIVE
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During visit conducted on 1/10/2024, LPA tested R1's call button in bathroom and observed staff respond to call in a timely manner. Interview with ED and multiple relevant parties indicated that R1 does not use and misplaces call button. Interview with ED indicated that R1 is no longer using a call button at the time of this report.

No interviews conducted during investigation indicated any concerns regarding care and supervision for R1. Interviews with staff indicated that 2 hour rounds are completed for all residents in the Memory Care Unit of the facility to provide care and supervision to the residents in care. Interview conducted with R1 indicated that they had no concerns regarding the facility, they have everything they need, they are treated well by staff, they have plenty to do, and their care needs are being met in the timely manner.

LPA observed an activities calendar for the Memory Care Unit of the facility and observed activities taking place throughout the facility during multiple visits. During multiple visits, LPA observed R1 participating in activities. Interviews with staff indicated that they have observed R1 actively participating in activities at the facility. Interview with staff and relevant party indicated that R1 has a hired companion every Monday, Wednesday, and Friday who ensures that R1 is participating in activities.

Based on interviews conducted, observations, and records reviewed, the preponderance of evidence standards have not been met. Therefore, the above allegations are found to be UNSUBSTANTIATED. A finding that a complaint allegation is unsubstantiated means that, although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred.

Exit interview was conducted with ED. A copy of this report was provided. Signature on these forms acknowledges receipt of these documents.
SUPERVISOR'S NAME: Anthony PerezTELEPHONE: (323) 485-4915
LICENSING EVALUATOR NAME: Michael HoodTELEPHONE: (916) 531-7341
LICENSING EVALUATOR SIGNATURE:

DATE: 01/31/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/31/2024
LIC9099 (FAS) - (06/04)
Page: 5 of 5