345002797-5-10-2024-59-AS-KHOS-D6FVVV-20240621164659

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 345002797
Report Date: 05/10/2024
Date Signed: 05/10/2024 03:19:51 PM

Unfounded

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
04/29/2024 and conducted by Evaluator Michael Hood

COMPLAINT CONTROL NUMBER: 59-AS-20240429100901

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: 88	DATE:	05/10/2024
		UNANNOUNCED	TIME BEGAN:	02:45 PM
MET WITH:	Pouya Ansari, Executive Director		TIME COMPLETED:	03:30 PM

ALLEGATION(S):

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Staff are not following resident's care plan

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, LPA conducted interviews, 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 **

Unfounded

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: 05/10/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/10/2024

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-20240429100901

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: 05/10/2024

NARRATIVE

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During multiple visits conducted at the facility, LPA observed the facility to have four (4) hoyer lifts on cite and one (1) sit-to-stand lift on cite. LPA observed four (4) residents to be receiving assistance with a hoyer lift or sit-to-stand lift and reviewed their care plans to ensure that necessary care was documented. LPA observed staff schedule and observed a sufficient number of staff scheduled per shift.

Interviews conducted with staff members S1, S2, S3, and S4 indicated that they have never witnessed residents in need of a hoyer lift not receive staff assistance with a hoyer lift, never witnessed residents being lifted by staff in an unsafe way, and never witnessed residents not receiving services in accordance to their care plan. Interviews conducted with residents R1, R2, R3, R4, and R5 indicated that their care needs are being met at the facility. R1, R2, R3, and R4 confirmed that they use a hoyer lift or a sit-to-stand lift and indicated that they have had no bad experiences receiving care with the lift and no issues with safety regarding the lift.

Based on interviews conducted, observations, and records reviewed, the above allegation is found to be UNFOUNDED. A finding that the allegation is unfounded means that the allegation is false, could not have happened, and/or is without a reasonable basis.

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 Perez	TELEPHONE: (323) 485-4915
LICENSING EVALUATOR NAME: Michael Hood	TELEPHONE: (916) 531-7341
LICENSING EVALUATOR SIGNATURE:	DATE: 05/10/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/10/2024

LIC9099 (FAS) - (06/04)

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