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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 345002797
Report Date: 08/14/2025
Date Signed: 08/14/2025 04:32:05 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
05/29/2025 and conducted by Evaluator Michael Hood
COMPLAINT CONTROL NUMBER: 59-AS-20250529100321
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: 89DATE:
08/14/2025
UNANNOUNCEDTIME BEGAN:
12:35 PM
MET WITH:Pouya Ansari, AdministratorTIME COMPLETED:
04:45 PM
ALLEGATION(S):
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Facility staff are mismanaging residents' medication
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 a medication count, conducted interviews, and reviewed documentation pertinent to the investigation.

The results of the investigation are as follows:

Allegation: Facility staff are mismanaging residents' medication

** Report continued on 9099-C **
Substantiated
Estimated Days of Completion:
NAME OF LICENSING PROGRAM MANAGER: Anthony Perez
NAME OF LICENSING PROGRAM ANALYST: Michael Hood
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 08/14/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/14/2025
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 7
Control Number 59-AS-20250529100321
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: 08/14/2025
NARRATIVE
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LPA reviewed an Unusual Incident/Injury Report (SIR) for resident (R4) dated October 22, 2024 for an incident that occurred on October 21, 2024 regarding a medication error. SIR states that, on October 21, 2024, while conducting a weekly self Audit of the Assisted Living Med-Room, it was discovered by Health Services Director (HSD) that an order of Prednisone was being given to R4 incorrectly. Facility reported that the medication order was placed in the facility’s medication administration record from the pharmacy and an additional order on paper was placed in the system by a previous Director. One order stated morning dosage, and the second order stated evening dosage, creating confusion and wrong dosages given from September 22, 2024 to October 18, 2024. Upon discovery, the order was corrected and given as prescribed following correction. SIR states that facility would continue doing weekly audits of the Med-Room, HSD would be approving all orders, and an in-service training would be completed with Med-Techs.

On June 3, 2025, LPA conducted a medication count for residents R1, R2, and R3, comparing each resident’s Centrally Stored Medication Form (CSM) and Medication Administration Record (MAR) with medications centrally stored for the residents. LPA observed two (2) of five (5) medications for R1 were over the amount documented by two (2) tabs. After missed passes were factored into count, R1's MAR did not include any additional information to justify the two (2) medications over by two (2) tabs. LPA observed four (4) of five (5) medications for R2 to be off-count in relation to the amount documented. One (1) medication for R2 should have been finished and still had four (4) tabs available, one (1) medication was over by one (1) tab, one (1) medication was over by four (4) tabs, and one (1) medication was under by 20 tabs. R2's MAR did not indicate any refusals or missed passes of medication, nor did it indicate any reason for medications to be under the amount documented. LPA observed three (3) of seven (7) medications for R3 to be off-count in relation to the amount documented. One (1) medication for R3 should have been finished and still had nine (9) tabs available, one (1) medication was over by two (2) tabs, and one (1) medication was over by three (3) tabs. R3's MAR did not indicate any refusals or missed passes of medication, nor did it indicate any reason for medications to be under the amount documented.

Based on medication count 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. A copy of this report was provided. Signature on these forms acknowledges receipt of these documents.
NAME OF LICENSING PROGRAM MANAGER: Anthony Perez
NAME OF LICENSING PROGRAM ANALYST: Michael Hood
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 08/14/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/14/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 7
Control Number 59-AS-20250529100321
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: 08/14/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Request Denied
Type A
08/15/2025
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 had a office meeting with Community Care Licensing and will continue to implement plan that was established during meeting. In-service will be conducted with med-techs, Health Services Director, Memory Care Director, and Resident Care Coordinator.
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Based on medication counts and records reviewed, the facility did not ensure that residents R1, R2, R3, and R4 were receiving medications as prescribed, which poses an immediate health, safety, and personal rights risk to residents in care.
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Facility will submit time of training and training agenda by POC due date of 8/15/2025.
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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.
NAME OF LICENSING PROGRAM MANAGER: Anthony Perez
NAME OF LICENSING PROGRAM ANALYST: Michael Hood
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 08/14/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/14/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 7
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
05/29/2025 and conducted by Evaluator Michael Hood
COMPLAINT CONTROL NUMBER: 59-AS-20250529100321

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: 89DATE:
08/14/2025
UNANNOUNCEDTIME BEGAN:
12:35 PM
MET WITH:Pouya Ansari, AdministratorTIME COMPLETED:
04:45 PM
ALLEGATION(S):
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Facility staff are not providing assistance with ADLs
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 interviews and toured the premises.

The results of the investigation are as follows:

Allegation: Facility staff are not providing assistance with ADLs

** Report continued on 9099-C **
Unsubstantiated
Estimated Days of Completion:
NAME OF LICENSING PROGRAM MANAGER: Anthony Perez
NAME OF LICENSING PROGRAM ANALYST: Michael Hood
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 08/14/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/14/2025
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 7
Control Number 59-AS-20250529100321
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: 08/14/2025
NARRATIVE
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Interviews with staff members S1, S2, S3, S4, S5, S6, and S7 indicated that they have never observed a resident in need of care and not receiving assistance from facility care staff. Interviews with residents R3, R5, R6, R7, and R8 indicated that they are treated well by facility staff and that their care needs are being met. Interviews with residents did not indicate any concerns regarding care staff providing assistance with ADLs. Interviews with residents indicated that they did not witness any residents in need of care and not receiving assistance from facility care staff. Interview with R3's authorized representative indicated that they have no concerns regarding care being provided to R3 and they felt caregivers do a good job providing care at the care home.

During visits conducted on June 3, 2025, July 30, 2025, August 7, 2025, August 13, 2025, and August 14, 2025, LPA did not observe any residents in need of care and not receiving assistance from facility care staff.

Based on interviews conducted and observations, 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. A copy of this report was provided. Signature on these forms acknowledges receipt of these documents.
NAME OF LICENSING PROGRAM MANAGER: Anthony Perez
NAME OF LICENSING PROGRAM ANALYST: Michael Hood
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 08/14/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/14/2025
LIC9099 (FAS) - (06/04)
Page: 5 of 7
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
05/29/2025 and conducted by Evaluator Michael Hood
COMPLAINT CONTROL NUMBER: 59-AS-20250529100321

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: 89DATE:
08/14/2025
UNANNOUNCEDTIME BEGAN:
12:35 PM
MET WITH:Pouya Ansari, AdministratorTIME COMPLETED:
04:45 PM
ALLEGATION(S):
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Facility is retaining residents beyond a level of care they can provide
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 interviews and reviewed documentation pertinent to the investigation.

The results of the investigation are as follows:

Allegation: Facility is retaining residents beyond a level of care they can provide

** Report continued on 9099-C **
Unfounded
Estimated Days of Completion:
NAME OF LICENSING PROGRAM MANAGER: Anthony Perez
NAME OF LICENSING PROGRAM ANALYST: Michael Hood
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 08/14/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/14/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 6 of 7
Control Number 59-AS-20250529100321
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: 08/14/2025
NARRATIVE
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Relevant party reported to the Department that resident (R3) was observed to be residing in the Assisted Living Unit (ALU) of the facility while participating in activities and spending most daytime hours in the Memory Care Unit (MCU) of the facility. A review of Title 22 regulations did not indicate any violations distinguishing care needs of residents in ALU settings in opposition to care needs of residents in MCU settings.

Interviews with staff members S1, S2, S3, S4, S5, S6, and S7 indicated that they have never observed the facility retaining residents beyond a level of care they can provide, including prohibited health conditions. Interviews with residents R7 and R8 indicated that they have never witnessed residents residing at the facility who are in need of a level of care the facility cannot provide.

LPA reviewed records for R3, including R3's Physician's Report (LIC 602A) dated July 10, 2024 and Resident Assessments dated October 13, 2023, April 3, 2024, July 12, 2024, December 12, 2024, January 1, 2025, and June 19, 2025, which did not indicate that R3 sustained any prohibited health conditions or required a level of care that the facility could not provide. Interview with R3's representative indicated that they had no concerns regarding the care provided at the facility and they feel care staff do a good job providing care to R3.

Based on interviews conducted 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. A copy of this report was provided. Signature on these forms acknowledges receipt of these documents.
NAME OF LICENSING PROGRAM MANAGER: Anthony Perez
NAME OF LICENSING PROGRAM ANALYST: Michael Hood
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 08/14/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/14/2025
LIC9099 (FAS) - (06/04)
Page: 7 of 7