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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 345002797
Report Date: 10/18/2023
Date Signed: 10/18/2023 05:00:02 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
09/29/2023 and conducted by Evaluator Michael Hood
COMPLAINT CONTROL NUMBER: 59-AS-20230929105355
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:
10/18/2023
UNANNOUNCEDTIME BEGAN:
03:10 PM
MET WITH:Pouya Ansari, Executive DirectorTIME COMPLETED:
05:00 PM
ALLEGATION(S):
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Staff did not give resident's medication as prescribed

Facility is not providing PPE to staff who are in direct contact with residents with a contagious disease
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, LPA conducted interviews, conducted a medication count, conducted a tour of the facility, 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 PerezTELEPHONE: (323) 485-4915
LICENSING EVALUATOR NAME: Michael HoodTELEPHONE: (916) 531-7341
LICENSING EVALUATOR SIGNATURE:

DATE: 10/18/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/18/2023
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 4
Control Number 59-AS-20230929105355
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: 10/18/2023
NARRATIVE
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During a visit conducted on 10/05/2023, LPA conducted a medication count for resident R1, comparing the resident’s Centrally Stored Medication Form (CSM) with medications centrally stored for the resident. LPA observed one (1) medication for R1 that was off count in relation to what was documented. Medication that was off count was over the amount documented. There were no documented refusals for R1’s medication when reviewing R1's medication Admin History. LPA reviewed Shift Reports and observed that it was noted under NOC shift notes for 9/22/2023 that new medications for R1 were delivered and ready to use at 4:00 AM on 9/22/2023 despite R1's medication not being documented as given until 9/23/2023. Interviews conducted indicated that the documented date for when medications were received was incorrect.

On 10/06/2023, ED informed LPA that they began conducting an internal investigation and discovered that bubble pack for R1's medication had tape on the back of the bubble pack, indicating that pills had been placed in the pack after the seal had been broken. ED also discovered a bottle of the same medication for resident (R2) that was supposed to be destroyed underneath a staff member's (S2's) desk with tin foil inside the bottle. ED stated that there was no documentation indicating that R2's medication had been destroyed or removed from the medication room.

During a visit conducted on 10/05/2023, LPA conducted a tour of the facility to inspect facility's Personal Protective Equipment (PPE). LPA observed facility had a sufficient supply of N-95 respirators, surgical masks, gloves, face shields, gowns, and hand sanitizer. LPA observed one (1) resident on isolation due to COVID-19 exposure and COVID-19 symptoms (resident refused to test). LPA observed PPE cart outside of resident's apartment and observed cart did not have N-95 respirators. LPA also did not observe PPE instructions posted outside of resident's apartment. LPA interviewed representative from Sacramento County Public Health. They stated that they still advise staff working at long-term care facilities to use full PPE when caring for residents who are in isolation due to COVID-19 per PIN 23-13-ASC. PIN 23-13-ASC states the following: "Important! Facility staff must wear the appropriate PPE (i.e., N95 respirator, and gloves) pursuant to facility specific regulations. Licensees are encouraged to have signage in the facility on proper PPE donning and doffing."

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

DATE: 10/18/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/18/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 4
Control Number 59-AS-20230929105355
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: 10/18/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Request Denied
Type A
10/19/2023
Section Cited
CCR
87465(a)(4)
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87465 Incidental Medical and Dental Care (a) A plan for incidental medical and dental care shall be developed by each facility (...) by compliance with the following: (4) The licensee shall assist residents with self-administered medications as needed. This requirement is not met as evidenced by:
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Facility will complete an inservice with staff regarding medication administration. Facility will also continue bi-weekly medication audits. Facility will submit to LPA information regarding in-service training and medication audit, including time and date of in-service and training material, by POC due date.
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Based on medication counts and records reviewed, the facility did not ensure that resident R1 was receiving medications as prescribed, which poses an immediate health, safety, and personal rights risk to residents in care.
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A civil penalty of $250 is assessed for a repeated violation.
Request Denied
Type B
11/02/2023
Section Cited
CCR
87468.1(a)(2)
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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:
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Facility will complete an inservice with staff on proper donning and doffing of PPE. Facility will submit training documents to LPA by POC due date. A civil penalty of $250 is assessed for a repeated violation.
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Based on observation, facility did not ensure that staff were wearing full PPE when working with residents on isolation for COVID-19, which poses a potential health, safety, and personal rights risk to the residents in care.
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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: 10/18/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/18/2023
LIC9099 (FAS) - (06/04)
Page: 3 of 4
Control Number 59-AS-20230929105355
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: 10/18/2023
NARRATIVE
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Based on interviews conducted, a medication count, observation, 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. Two civil penalties in the amount of $250 are assessed for the date of 10/18/2023 for repeat violations within 12 months of a prior violation of a statutory or regulatory provision designated by the same combination of letters or numerals per Health and Safety Code §1548.

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 PerezTELEPHONE: (323) 485-4915
LICENSING EVALUATOR NAME: Michael HoodTELEPHONE: (916) 531-7341
LICENSING EVALUATOR SIGNATURE:

DATE: 10/18/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/18/2023
LIC9099 (FAS) - (06/04)
Page: 4 of 4