345002797-9-22-2026-59-AS-LCRR-DYEVAG-20260930161553

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 345002797
Report Date: 09/22/2026
Date Signed: 09/22/2026 02:11:14 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
04/03/2026 and conducted by Evaluator Sabrina Calzada

PUBLIC

COMPLAINT CONTROL NUMBER: 59-AS-20260403150731

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: 84	DATE:	09/22/2026
		UNANNOUNCED	TIME BEGAN:	01:45 PM
MET WITH:	Anyssa Hill, Administrator		TIME COMPLETED:	02:20 PM

ALLEGATION(S):

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Facility staff are not providing proper assistance with oxygen for residents in need.
Facility staff are not safeguarding residents’ property.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Sabrina Calzada arrived unannounced to deliver findings to a complaint received on April 3, 2026 and met with Anyssa Hill, Administrator. LPA stated the reason for today's inspection. Also present was Alexis Mendoza, Memory Care Director.

During the investigation, LPA interviewed multiple facility staff, from all shifts, managers, Resident (R1), and (3) family members of (R1). LPA reviewed related documentation, including (R1's) Physician's Report, care plan, oxygen orders, Medication Administration Record (April/May 2026), and other documentation. The results of the investigation are as follows:

(R1) moved to the community in September 2018 and to the Memory Care Unit on/around 2023. The Physician's report (dated 6/14/2024) notes (R1) has a diagnosis of Lower GI Hemorrhage, Diverticulitis, Dementia, Paroxysmal Atrial Fibrillation, has auditory/visual impairments, bowel/bladder incontinence, is able to communicate/follow instructions, and needs assistance with all Activities of Daily Living (ADL's) but feeding. Additionally, the Physician's Report notes that (R1) does not show any aggressive, wandering or sundowning behaviors.

9*report cont on 9099C-1..

Substantiated

Estimated Days of Completion:

SUPERVISORS NAME: Lauren Crocker
LICENSING EVALUATOR NAME: Sabrina Calzada
LICENSING EVALUATOR SIGNATURE:	DATE: 09/22/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/22/2026

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-20260403150731

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: 09/22/2026

NARRATIVE

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9099C-1.. (R1's) care plan was updated on March 17, 2026, due to a change in condition. The care plan notes (R1) is hearing impaired and needs assistance from a care provider with hearing aid care (batteries adjustments, etc). Additionally, the care plan states (R1) requires assistance with medication, toileting, can walk to/from the dining room and to all activities within the facility, is on fall management program, uses oxygen and requires assistance and monitoring from staff in turning the machine on/off and putting the canula on. This care plan states that (R1) does not require breathing treatments. (R1) was admitted to hospice on August 23, 2025 and discharged on February 13, 2026. Home Health was initiated on April 10, 2026, and (R1) was re-admitted to hospice May 15,2026.

Allegation: Facility staff are not providing proper assistance with oxygen for residents in need. The allegation states staff did not ensure resident (R1) received the necessary oxygen causing their oxygen saturation level to drop to around 70 percent on March 31, 2026.

On April 22, 2026, one of (R1’s) family members stated that on March 31, 2026, a Med-Tech staff called another family member to report that (R1) was off baseline and needed to be sent out for further evaluation. (R1) was sent out, hospitalized and returned (2) days later with a prescription for antibiotics due to a diagnosis of a Urinary Tract Infection (UTI). This family member confirmed (R1) cannot self manage their oxygen, is compliant with using oxygen most of the time, but sometimes will put the nasal canula in their mouth.

This family member provided additional information that a second family member called the facility one time and was not sure if (R1) was "plugged in" as their oxygen was between 80 and 90 percent. When this same family member was visiting, on a Tuesday evening, around 5:00-6:00 pm, they observed that the tubing to the oxygen machine was disconnected.

LPA was copied in an email sent by this second family member to the prior Administrator, and other managers, on June 18, 2026, with concerns about staff ensuring that (R1’s) portable oxygen machine is fully charged, hooked up properly, set on the correct oxygen level, and the charging cord goes with (R1) when leaving their room. This family member expressed concerns about staff "not ensuring the oxygen tubing is actually attached to the concentrator when transferring (R1) from the portable unit to the concentrator", and stated to LPA, and the current Administrator, on September 9, 2026, that there have been ongoing issues with the portable oxygen machine that started prior to the last Administrator, including the machine not being on, not on (R1’s) face, and not being plugged in. This family member asserted, "I mentioned to staff to charge the battery as it has also been an issue" and expressed on September 9, 2026, “there are no issues currently".

*cont on 9099C-2..

SUPERVISORS NAME: Lauren Crocker
LICENSING EVALUATOR NAME: Sabrina Calzada
LICENSING EVALUATOR SIGNATURE:	DATE: 09/22/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/22/2026

LIC9099 (FAS) - (06/04)

Page: 4 of 7

Control Number 59-AS-20260403150731

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: 09/22/2026

NARRATIVE

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9099C-2. A third family member provided information to the LPA and the Administrator, on September 9, 2026, regarding (R1's) portable oxygen machine, stating, “there were periods of time where there were issues- the batteries were acting up or not keeping a charge- staff is supposed to keep (R1) by an electric charge" in the dining room should the battery needs charging. This family member asserted, "there were instances that the unit was not plugged in and (R1) was not seated by an outlet", as well as times when "the canula was on (R1's) face, but the battery was not working or charged". Both this family member and a second family member indicated they could not recall any instances of where a UTI alone caused (R1’s) oxygen levels to drop notably.

Multiple staff stated that (R1) uses oxygen 24/7, they often find (R1) with the nasal canula piece in their mouth, and staff will assist (R1) with placing it back in their nose. Staff also confirmed (R1) uses the portable machine when they are out of their room and the stationary machine when in their room". Multiple staff interviews revealed that staff must be watching (R1) very frequently to ensure (R1) does not take the oxygen nasal canula out of their nose.

Staff were asked about charging the portable and large oxygen machine in (R1's) room. One caregiver explained, "we only have to be sure it's fully charged- we charge the portable all night- 8 hours” and confirmed the stationery machine is "always plugged in" and staff do “check that the tubing (white and green) is connected all the time. Another staff stated on May 7, 2026, " it is not an issue with the portable unit not being charged- (R1) got a new battery for the portable", explaining (R1) will get up for breakfast and staff will put the portable oxygen on (R1) and staff will switch back to the big tank after breakfast".

One caregiver staff stated that staff have received training on the "big oxygen machine- we make sure it's plugged in" and confirmed staff complete all their training on the computer using an approved training vendor, and hospice has not given staff any training. A NOC shift Med-Tech confirmed they "check if the portable machine is charged- I also make sure the large machine is charged. (R1) has an extra portable machine- I make sure it's plugged in all the way".

The facility’s charting notes created on March 31, 2026 (2:37 pm) state (R1) was sent out for further evaluation due to confusion and hallucinations and returned to the community on April 2, 2026 (8:39 pm) with orders to begin antibiotics for a diagnosed UTI. The facility incident report completed on April 1, 2026, notes that (R1) was sent out on March 31, 2026, due to “altered mental status with hallucinations”.

*cont on 9099C-3..

SUPERVISORS NAME: Lauren Crocker
LICENSING EVALUATOR NAME: Sabrina Calzada
LICENSING EVALUATOR SIGNATURE:	DATE: 09/22/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/22/2026

LIC9099 (FAS) - (06/04)

Page: 3 of 7

Control Number 59-AS-20260403150731

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: 09/22/2026

NARRATIVE

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cont on 9099C-3.. LPA observed (R1) on multiple occasions at the facility during the investigation. On May 7, 2026, LPA observed (R1) seated in their wheelchair wearing the oxygen canula that was hooked up to the main oxygen machine (11:00 am) which was plugged in and operating. LPA also observed the portable oxygen machine and nebulizer to be plugged into the charger on the floor. (R1) stated to LPA they need staff assistance with using oxygen. On July 15, 2026, and September 1, 2026, LPA observed (R1) to be wearing their nasal canula that was attached to their portable oxygen unit, while in the common area. On September 9, 2026, LPA observed (R1) to be resting in their room and wearing the oxygen nasal canula correctly.

The Department received prior complaints regarding (R1’s) oxygen not being administered as required. In November 2024, concerns were expressed about staff not assisting (R1) with their oxygen usage, not plugging in (R1's) portable oxygen machine to ensure it is charged and operable when (R1) is ambulating throughout the facility, resulting in (R1) going to the Emergency Room the month before for low oxygen levels. Based on information obtained during the investigation, the allegation was found to be Unsubstantiated.

In September 2023, the allegation that staff did not ensure the PRN order for oxygen was followed while (R1) was ambulating or active in the facility was investigated and found to be Substantiated.

LPA reviewed a “Pre-Hospital Care Report” from an ambulance service, dated March 31, 2026, documenting that the facility contacted them (12:33 pm) due to (R1) being lethargic. The report notes that upon arriving at the Memory Care Unit (12:49 pm), (R1) was observed to be “seated in a wheelchair inside the memory care dining room” and to be “hypoxic with initial room air oxygen saturation of 76 percent” (12:49 pm). (R1) was immediately given oxygen (6 liters/minute), raising the oxygen saturation level to 86 percent (12:56 pm), given additional oxygen (12 liters/minute), and taken out for emergency medical treatment, remaining hospitalized for (2) days.

Based on information obtained during the investigation, the Department finds the allegation to be SUBSTANTIATED- A finding that the complaint is Substantiated means that the allegation is valid because the preponderance of the evidence standard has been met.

*cont on 9099C-4..

SUPERVISORS NAME: Lauren Crocker
LICENSING EVALUATOR NAME: Sabrina Calzada
LICENSING EVALUATOR SIGNATURE:	DATE: 09/22/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/22/2026

LIC9099 (FAS) - (06/04)

Page: 5 of 7

Control Number 59-AS-20260403150731

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: 09/22/2026

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 10/06/2026 Section Cited CCR 87618(b)(5)	1 2 3 4 5 6 7	87618 Oxygen Administration - Gas and Liquid (b) In addition to Section 87611(b), the licensee shall be responsible for the following: (5) Ensuring that facility staff have knowledge of, and ability in the operation of the oxygen equipment. This requirement is not met as evidenced by:	1 2 3 4 5 6 7	Licensee/Administrator agree to conduct staff training on utilizing a portable oxygen machine, including how to ensure the unit is charged and operating correctly. The Administrator stated she will schedule a care meeting with (R1's) family to discuss the facility's ability to meet (R1's) needs.
	8 9 10 11 12 13 14	Based on interviews conducted and documentation reviewed, the Licensee did not ensure that (R1) received the required oxygen to maintain safe levels on March 31, 2026, by ensuring staff had the knowledge and ability to ensure (R1's) portable oxygen unit was operating correctly and (R1) was correctly wearing the nasal canula, which posed an immediate health and safety risk to residents in care. (R1's) oxygen saturation level was found to be 76 percent on March 31, 2026 (12:49 pm), when (R1) was seated in the dining room.	8 9 10 11 12 13 14	Documentation due to LPA by October 6, 2026.
Type B 10/06/2026 Section Cited CCR 87468.1(a)(12)	1 2 3 4 5 6 7	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: (12) To wear their own clothes; to keep and use their own personal possessions, including their toilet articles; and to keep and be allowed to spend their own money. This requirement is not met as evidenced by:	1 2 3 4 5 6 7	Licensee/Administrator agree to conduct training on (R1's) laundry process to ensure her clothes are correctly returned after being washed. The Administrator will also communicate with (R1's) family to ensure that all of (R1's) belongings have been labeled and all of the items that do not belong to (R1) are removed from (R1's) apartment.
	8 9 10 11 12 13 14	Based on interviews conducted and photo documentation, the Licensee did not ensure that (R1/s) oximeter/s, hearing aids and clothing did not go missing from their room, on/around October-November 2025, which posed a potential health and safety risk to residents in care.	8 9 10 11 12 13 14	Documentation due to LPA by October 6, 2026.

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: Lauren Crocker
LICENSING EVALUATOR NAME: Sabrina Calzada
LICENSING EVALUATOR SIGNATURE:	DATE: 09/21/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/21/2026

LIC9099 (FAS) - (06/04)

Page: 2 of 7

Control Number 59-AS-20260403150731

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: 09/22/2026

NARRATIVE

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9099C-5.. Allegation: Facility staff are not safeguarding residents’ property. The allegation states (R1) has had oximeters, hearing aids and clothing go missing.

One family member stated (R1) has lost (6) oximeters since moving in. A second family member stated that (R1) has lost “several oximeters”. Interviews revealed that most staff were not aware that (R1) had a oximeter/s with one staff stating, "I recall one time it was lost and it was replaced" and indicated the facility also has their own oximeter, which is kept in the Med Room. This staff stated (R1) now keeps the oximeter in a pouch in their room for safe keeping.

Only (1) staff recalled hearing aids being lost and stated, "(R1) lost one pair or one left or right hearing aids a while ago, but they found it", adding, "it was two times max" that this happened. This staff commented that (R1) "wears glasses, oxygen and hearing aids on their ears", so one of them may have fallen off. This staff stated in September that "now (R1's) hearing aids are strung together and kept in the Med Room at night, and the instructions for use are listed on the Medication Administration Record (MAR). LPA observed the instructions for putting hearing aids on in the morning, removing them at night, and placing them on the charger to be noted on the April and May 2026 MARs.

One family member stated that when she visited in October 2025, one of (R1's) hearing aids had been lost as well as their glasses, and it was reported to management when both items went missing.

The prior administrator stated on June 19, 2026, in an email to the family, that the facility suggested (R1) use clips to keep the hearing aids attached to their clothing and to prevent loss. The prior Memory Care Director confirmed staff are putting the hearing aids back in (R1s) ears, as "there are times that (R1) removes them, just like how they remove the oxygen tubes".

One family member stated she visited in October 2025 and "as of last October, everything I have bought (R1), including towels have been marked with a permanent marker with (R1's) initials and/or other identifier like the room number." This family member stated another family member reported to them in November 2025, that most of the newly purchased clothing was missing.

On May 7, 2026, LPA checked many pieces of clothing in (R1’s) closet, with their permission, and saw multiple sized clothing, including sizes XS, L, and XL, that were not labeled with (R1's) initials. LPA observed a jacket in (R1’s) room to have their initials and room number noted on the tag.

*cont on 9099C-6

SUPERVISORS NAME: Lauren Crocker
LICENSING EVALUATOR NAME: Sabrina Calzada
LICENSING EVALUATOR SIGNATURE:	DATE: 09/22/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/22/2026

LIC9099 (FAS) - (06/04)

Page: 6 of 7

Control Number 59-AS-20260403150731

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: 09/22/2026

NARRATIVE

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9099C-6.. A Med-Tech stated that clothing sometimes does get delivered to another resident's room, but staff return it to (R1) when it's noticed. The Med-Tech stated that the "pm" staff doesn't always use magnetic sticky notes to identify a resident's laundry when it's being washed, and the "am" shift doesn't always put a resident's clean laundry back in their dresser or closet. LPA could not observe any laundry being washed/dried since it is completed on the NOC shift.

The prior Administrator stated "staff can't really tell what is missing" and explained that (R1)"lost weight" and that's why there are different sizes, commenting, "four family members, including the son's wife, are in and out all of the time" and not all of (R1's) clothing is consistently labeled.

Staff interviews revealed a mixed result. One staff stated, "Sometimes all residents’ clothes get mixed up and a lot of items are labeled- caregivers will do room sweeps- if they notice an item is misplaced, they will take it to the correct room". Other staff stated that (R1) has not had any clothing disappear from their room. A family member confirmed in September 2026 that (R1) lost weight since moving to Memory Care and is currently wearing a smaller size than previously worn, but shows up in clothing that is not theirs, and the new clothes are not found in (R1’s) room.

A family member emailed the facility on June 18, 2026, and included a photo of (R1) wearing another resident's sweater. The photo also showed (R1) to not have both hearing aids placed in their correct ears. A second and third family member confirmed that some of (R1’s) clothing has gone missing. On September 16, 2026, LPA was provided with a photo from a family member of (R1) wearing clothing within the last week that is not theirs. On September 14, 2026, LPA was provided with another photo of (R1) wearing pants and a top that day that do not belong to them. On September 12, 2026, LPA was provided with a another photo, taken on September 11, 2026, of (R1) wearing clothing that day that does not belong to them.

Based on interviews conducted, observations, and photo documentation, the allegation is found to be SUBSTANTIATED- A finding that the complaint is Substantiated means that the allegation is valid because the preponderance of the evidence standard has been met.

Per California Code of Regulations, Title 22, Division 6, Chapter 8, the following (2) deficiencies are cited on the 9099D page. Exit interview. Copy of report and appeal rights provided.

Exit interview. Copy of report and appeal rights provided.

SUPERVISORS NAME: Lauren Crocker
LICENSING EVALUATOR NAME: Sabrina Calzada
LICENSING EVALUATOR SIGNATURE:	DATE: 09/22/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/22/2026

LIC9099 (FAS) - (06/04)

Page: 7 of 7