345002797-5-12-2023-25-AS-APEZ-CRXNJ6-20230518102946

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 345002797
Report Date: 05/12/2023
Date Signed: 05/12/2023 12:49:41 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, 2525 NATOMAS PARK DR STE 270
SACRAMENTO, CA 95833

This is an official report of an unannounced visit/investigation of a complaint received in our office on
11/30/2022 and conducted by Evaluator Michael Hood

COMPLAINT CONTROL NUMBER: 25-AS-20221130135019

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:	05/12/2023
		UNANNOUNCED	TIME BEGAN:	12:05 PM
MET WITH:	Pouya Ansari, Executive Director		TIME COMPLETED:	01:05 PM

ALLEGATION(S):

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Facility does not have adequate staffing to meet resident's needs.

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 conclude a complaint investigation into the allegation listed above.

During the investigation, LPA conducted interviews and reviewed documentation pertinent to the investigation.

The results of the investigation are as follows:

Allegation: Facility does not have adequate staffing to meet resident's needs.

** 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: 05/12/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/12/2023

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 25-AS-20221130135019

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 2525 NATOMAS PARK DR STE 270
SACRAMENTO, CA 95833

FACILITY NAME: OAKMONT OF FAIR OAKS	FACILITY NUMBER: 345002797
	VISIT DATE: 05/12/2023

NARRATIVE

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Interview with staff member (S1) indicated that staffing could be better at the facility and that the facility needs more staffing. Interview with staff member (S2) indicated that PM shift in the Memory Care Unit (MCU) needs more staffing and that they noticed a lot of "call-offs" in the MCU during PM shift. Interview with staff member (S3) indicated that staffing at the facility could be improved and working at the facility can be "hectic." Interview with resident (R1) indicated that they have used their call button pendant and will have to wait for staff’s response anywhere between 10 to 20 minutes, and has waited 40 minutes not receiving staff assistance and needing to contact the front desk for staff to respond.

Interview with ED indicated that standard response time to residents' call buttons
is between 5 to 10 minutes, with no more than 15 minutes passing before responding to a resident's call button. ED stated that fall sensors should be responded to by staff immediately.

LPA reviewed History of SMARTcare (call button response time records) for 12/4/2022 through 12/6/2022, 12/21/2022 through 12/22/2022, and 12/26/2022 through 1/10/2023. At multiple times through the dates listed above, LPA observed call buttons "announced 9 times" with no time indicated when response was given. At multiple times through the dates listed above, LPA observed call buttons have response times exceeding 15 minutes and reaching as long as 42 minutes. LPA observed call button logs for R1 to have multiple response times exceeding 15 minutes and reaching as long as 38 minutes.

Based on interviews conducted by the department and records reviewed, 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. The 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: 05/12/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/12/2023

LIC9099 (FAS) - (06/04)

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Control Number 25-AS-20221130135019

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 2525 NATOMAS PARK DR STE 270
SACRAMENTO, CA 95833

FACILITY NAME: OAKMONT OF FAIR OAKS	FACILITY NUMBER: 345002797
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 05/12/2023

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Request Denied Type B 05/31/2023 Section Cited CCR 87411(a)	1 2 3 4 5 6 7	87411 Personnel Requirements - General (a) Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs. This requirement is not met as evidenced by:	1 2 3 4 5 6 7	ED will ensure that call button system is correctly operating to ensure accurate response times. ED will conduct a training regarding proper call button clearance and response time management on before POC due date. ED will provide training materials and sign-in roster of those who attended to department by POC due date.
	8 9 10 11 12 13 14	Based interviews conducted and records reviewed, the facility did not ensure call buttons for residents were responded to in a timely manner, resulting in response times reaching as long as 42 minutes, which poses a potential health, safety, and personal rights risk to residents in care.	8 9 10 11 12 13 14
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	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: Anthony Perez	TELEPHONE: (323) 485-4915
LICENSING EVALUATOR NAME: Michael Hood	TELEPHONE: (916) 531-7341
LICENSING EVALUATOR SIGNATURE:	DATE: 05/12/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/12/2023

LIC9099 (FAS) - (06/04)

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