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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 345002797
Report Date: 09/14/2022
Date Signed: 09/14/2022 09:47:24 AM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 520 COHASSET RD., STE. 170
CHICO, CA 95926
This is an official report of an unannounced visit/investigation of a complaint received in our office on
05/04/2022 and conducted by Evaluator Sabrina Calzada
PUBLIC
COMPLAINT CONTROL NUMBER: 25-AS-20220504080347
FACILITY NAME:OAKMONT OF FAIR OAKSFACILITY NUMBER:
345002797
ADMINISTRATOR:CONDIE, NATHANFACILITY TYPE:
740
ADDRESS:8484 MADISON AVE.TELEPHONE:
(916) 633-1001
CITY:FAIR OAKSSTATE: CAZIP CODE:
95628
CAPACITY:128CENSUS: 73DATE:
09/14/2022
UNANNOUNCEDTIME BEGAN:
08:50 AM
MET WITH:Pouya Ansari, Administrator TIME COMPLETED:
09:50 AM
ALLEGATION(S):
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Staff failed to respond to resident’s call button
Staff left resident unattended for an extended period of time
Untrained staff
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Sabrina Calzada arrived unannounced to deliver findings to a complaint received on May 4, 2022. LPA met with Pouya Ansari, Executive Director, and explained purpose of inspection. (NOTE: LPA was at the facility on 9/13/2022 to complete the complaint and deliver findings; however due to technical and other issues, the complaint findings were not able to be delivered then)
Prior to initiating today's inspection, LPA completed required COVID-19 testing protocols and completed a daily self-screening questionnaire for symptoms of COVID-19 infection to affirm no COVID-19 related symptoms. Additionally, LPA was screened per Covid-19 precautionary measures upon entering the community. LPA ensured she applied hand sanitizer before entering the facility and the following Personal Protective Equipment (PPE) was worn: surgical mask.

During the investigation, LPA interviewed Resident Care Coordinator (RCC), current Administrator and Health and Services Director, Marketing Director, (2) staff who work on NOC shift and resident (R1). LPA reviewed documentation pertaining to resident (R1): including. but not limited to: pre-appraisal, physician's report, care plan, pendant response report, Assisted Living staffing schedules for May 2022, and staff training records.

The results of the investigation are as follows:
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Maribeth SentyTELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Sabrina CalzadaTELEPHONE: (510) 829-2133
LICENSING EVALUATOR SIGNATURE:

DATE: 09/14/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/14/2022
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 8
Control Number 25-AS-20220504080347
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 520 COHASSET RD., STE. 170
CHICO, CA 95926
FACILITY NAME: OAKMONT OF FAIR OAKS
FACILITY NUMBER: 345002797
VISIT DATE: 09/14/2022
NARRATIVE
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9099C(1)..Resident moved to the facility on/around 2/27/22. Pre-appraisal documents that resident is visually impaired and uses a walker and service animal for balance due to a diagnosis of ataxia and does not need special observation or night supervision due to confusion, forgetfulness and/or wandering. Resident’s care plan was updated on 4/22/22 due to a change in condition- all service points allocated to additional housekeeping and pet care (walks 3x/day). Resident has resided in the Assisted Living Unit (ALU) since moving in and resident's physician's report, dated 2/27/2022, notes that resident does not have a diagnosis of Dementia or Mild Cognitive Impairment.

Allegation: Staff failed to respond to resident’s call button.
Allegation states that staff did not respond timely to resident’s call assistance button pressed initially after resident fell, and repeatedly throughout the night, until 5:30 am.

Resident (R1) stated in an interview that she fell on 4/20/2022 at approximately 10:45 pm and was able to get up within 10 minutes from the floor by herself and "was able to move her legs and arms and had her phone handy" and called staff for assistance. Resident stated she also has a lanyard pendant and wears it day and night", and after falling on 4/20/22, she kept pushing the pendant and calling every 10 minutes throughout the night, until 5:45 am when staff (S1 and S2) finally showed up. Resident explained she "doesn't know why staff never answered" and that 15 minutes is the normal response time and stated that staff gets so many calls they can't tell if they are "new calls or old calls" coming in and the pendant "should be for emergency use but is used indiscriminately".

Staff (S1) who worked during the NOC shift on 4/20/2022, stated that around 10:15 pm she and Med-Tech staff (S2) walked by resident's door as they were transitioning to do rounds in Memory Care and heard what sounded like resident talking on the phone. S1 stated that resident (R1) is not checked on regularly throughout the day or night, based on her care plan and only residents in the Memory Care Unit are checked on regularly. S1 stated she noticed her pager went off around 4-4:30 am on 4/21/2022 for resident's room and responded very promptly, as she does everytime the pager goes off. S1 stated that her pager has always worked correctly and when she starts a shift, she makes sure to clear the pager so there are no calls pending from the prior shif. S1 confirmed she received calls from other residents during her shift from 4/20/2022- 4/21/2022 and always carries a pager with her during her shift.
cont on 9099C(2)..
SUPERVISOR'S NAME: Maribeth SentyTELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Sabrina CalzadaTELEPHONE: (510) 829-2133
LICENSING EVALUATOR SIGNATURE:

DATE: 09/14/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/14/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 8
Control Number 25-AS-20220504080347
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 520 COHASSET RD., STE. 170
CHICO, CA 95926
FACILITY NAME: OAKMONT OF FAIR OAKS
FACILITY NUMBER: 345002797
VISIT DATE: 09/14/2022
NARRATIVE
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9099C(2). S1 confirmed that on 4/20/22- 4/21/22- only she and S2 were working and that she and S2 "do rounds together" so they can assist a resident who is a 2- person assist and "if the resident requires 1-person assistance, I will do it".

Staff (S2) stated S1 called her at approximately 4-4:30 am on 4/21/2022 after receiving an alert on her pager from resident and she met S1 in resident's room to check on her. Resident stated she had fallen around 10:00 pm earlier that night. S2 stated she looked at S1's pager and did not see any calls on her pager and stated that S1 does not know how to delete calls. S2 indicated also that staff do not check every resident every (2) hours in ALU unless it is noted on a resident's care plan. S2 asserted she did not receive any calls from resident (R1) on the Med-Tech cell phone she carried during the NOC shift on 4/20/2022- 4/21/2022.

S2 stated that in addition to pendant alerts going to the pagers, they will appear on the computer screen and that she "trains staff to confirm with the computer that calls are being picked up" , stating "the computer is more accurate". S1 stated she didn't think she needed to look at the computer screen since S2 "always looks at the screen" since she has worked there for several years. S1 stated on 9/12/2022 "now I am looking at the screen" but confirmed she was not doing it before since S2 "would always do that."

Both the RCC and Marketing Director stated in an interview on 6/8/2022 that the call pendant system is functioning correctly. The Maintenance Director stated on 9/12/2022 that maintenance will do routine, monthly checks on each resident's necklace or bracelet pendant, and additionally, the system will alert staff if a resident hasn't used a pendant in (2-3) weeks so it can be repaired, if needed. Additionally, the Maintenance Director confirmed there have been no issues with resident's (R1) pendant not working correctly, and there is no reason to believe the pendant wasn't working at any time.

Facility pendant response records and Med-Tech call records were no longer available after 5/20/2022, (30) days following resident's fall on 4/20/2022, and there was not an internal incident report or resident charting notes on file for review. Review of facility's pendant response records provided on 5/13/2022 for period 5/5/2022- 5/13/2022, note that resident (R1) pressed her pendant for assistance on 5/10/2022, at 2:47 pm, and received assistance within (11) minutes; however, the records show when (R1) pushed her pendant later in the day at 4:42 pm, and again at 5:52 pm, neither alert was responded to after it was announced (9) times.

Based on information obtained, LPA finds the allegation to be SUBSTANTIATED- A finding that the allegation is substantiated means that the allegation is valid because the preponderance of the evidence standard has been met.
cont on 9099C(3)..
SUPERVISOR'S NAME: Maribeth SentyTELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Sabrina CalzadaTELEPHONE: (510) 829-2133
LICENSING EVALUATOR SIGNATURE:

DATE: 09/14/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/14/2022
LIC9099 (FAS) - (06/04)
Page: 3 of 8
Control Number 25-AS-20220504080347
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 520 COHASSET RD., STE. 170
CHICO, CA 95926
FACILITY NAME: OAKMONT OF FAIR OAKS
FACILITY NUMBER: 345002797
VISIT DATE: 09/14/2022
NARRATIVE
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9099C(3) Allegation: Staff left resident unattended for an extended period of time
Allegation states that staff did not respond for hours after resident fell, until 5:30 am.

Resident stated to LPA that after falling on 4/20/2022 around 10:45 pm, she kept pushing the pendant and calling every (10) minutes throughout the night until 5:45 am when staff finally responded. Resident stated she "doesn't know why staff never answered". and discussed the situation with the Administrator at the time of the incident, and he "gave no explanation as to why staff took so long". Resident also stated that (15) minutes is the normal response times - and staff gets so many calls they can't tell if they are "new calls or old calls" coming in. Resident stated she was trying to call for assistance for (7) hours.

S1 stated when she and S2 arrived to resident's room on the morning of 4/21/2022, resident stated she was on the floor and that she had fallen but got up. S1 stated she called S2 to come over and access resident who told S2 she was "okay" and brought her ice. S1 stated she apologized to resident as she just saw her page when she responded, around 4:45 am.

Staffing records for April and May 2022 were requested on 5/13/2022, but only records for May 2022 were provided. May 2022 staffing schedules show that only (2) staff, (1) caregiver and (1) Med-Tech, are scheduled on the NOC shift. Interview with S1 confirmed she and S2 were the only staff working during the NOC shift from 4/20/2022- 4/21/2022.

Facility pendant response records were not available (30) days following the incident, or after 5/20/2022. Resident had a subsequent fall on 5/9/2022 and pushed her pendant for assistance on 5/9/2022 at 7:07 am and staff responded on 5/9/2022 at 7:49 am, after (9) announcements. Internal incident report was completed on 5/14/2022 and only notes a time of 7:07 am when resident fell. Resident charting notes are not available after 90 days.

Based on information obtained, LPA finds the allegation to be SUBSTANTIATED- A finding that the allegation is substantiated means that the allegation is valid because the preponderance of the evidence standard has been met.

cont on 9099C(4)..
SUPERVISOR'S NAME: Maribeth SentyTELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Sabrina CalzadaTELEPHONE: (510) 829-2133
LICENSING EVALUATOR SIGNATURE:

DATE: 09/14/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/14/2022
LIC9099 (FAS) - (06/04)
Page: 4 of 8
Control Number 25-AS-20220504080347
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 520 COHASSET RD., STE. 170
CHICO, CA 95926
FACILITY NAME: OAKMONT OF FAIR OAKS
FACILITY NUMBER: 345002797
VISIT DATE: 09/14/2022
NARRATIVE
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9099C(4) Allegation: Untrained staff. Allegation is staff are not trained.

LPA reviewed training documentation for (5) staff who currently work in the Assisted Living Unit. Documentation shows the on-line coursework completed for each staff since their hiring date and that (3) of (5) staff did not have all of the required initial or annual training completed per Health and Safety Code 1569.625 which states: (b)(1) The department shall adopt regulations to require staff members of residential care facilities for the elderly who assist residents with personal activities of daily living to receive appropriate training. This training shall consist of 40 hours of training. A staff member shall complete 20 hours, including six hours specific to dementia care, as required by subdivision (a) of Section 1569.626 and four hours specific to postural supports, restricted health conditions, and hospice care, as required by subdivision (a) of Section 1569.696, before working independently with residents. The remaining 20 hours shall include six hours specific to dementia care and shall be completed within the first four weeks of employment. The training coursework may utilize various methods of instruction, including, but not limited to, lectures, instructional videos, and interactive online courses. The additional 16 hours shall be hands-on training.

(2) In addition to paragraph (1), training requirements shall also include an additional 20 hours annually, eight hours of which shall be dementia care training, as required by subdivision (a) of Section 1569.626, and four hours of which shall be specific to postural supports, restricted health conditions, and hospice care, as required by subdivision (a) of Section 1569.696. This training shall be administered on the job, or in a classroom setting, or both, and may include online training.

Based on documentation reviewed, LPA finds the allegation to be SUBSTANTIATED A finding that the allegation is substantiated means that the allegation is valid because the preponderance of the evidence standard has been met.

Per California Code of Regulation, Title 22, Division 6, Chapter 8, the following (2) deficiencies are cited on the 9099-D page. Failure to correct the deficiency timely may result in a penalty being issued.

Exit interview. Copy of report and appeal rights provided.
SUPERVISOR'S NAME: Maribeth SentyTELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Sabrina CalzadaTELEPHONE: (510) 829-2133
LICENSING EVALUATOR SIGNATURE:

DATE: 09/14/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/14/2022
LIC9099 (FAS) - (06/04)
Page: 5 of 8
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 520 COHASSET RD., STE. 170
CHICO, CA 95926
This is an official report of an unannounced visit/investigation of a complaint received in our office on
05/04/2022 and conducted by Evaluator Sabrina Calzada
PUBLIC
COMPLAINT CONTROL NUMBER: 25-AS-20220504080347

FACILITY NAME:OAKMONT OF FAIR OAKSFACILITY NUMBER:
345002797
ADMINISTRATOR:CONDIE, NATHANFACILITY TYPE:
740
ADDRESS:8484 MADISON AVE.TELEPHONE:
(916) 633-1001
CITY:FAIR OAKSSTATE: CAZIP CODE:
95628
CAPACITY:128CENSUS: DATE:
09/14/2022
UNANNOUNCEDTIME BEGAN:
08:50 AM
MET WITH:Pouya Ansari, Administrator TIME COMPLETED:
09:50 AM
ALLEGATION(S):
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Resident sustained a fall while in care
INVESTIGATION FINDINGS:
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During the investigation, LPA interviewed Resident Care Coordinator (RCC), current Administrator and Health and Services Director, Marketing Director, (2) staff who work on NOC shift and resident (R1). LPA reviewed documentation pertaining to resident (R1): including. but not limited to: pre-appraisal, physician's report, and care plan.

The results of the investigation are as follows:

Resident moved to the facility on/around 2/27/22. Pre-appraisal notes that resident is visually impaired and uses a walker and service animal for balance due to a diagnosis of ataxia and does not need special observation or night supervision due to confusion, forgetfulness and/or wandering. Per resident's physician's report, dated 2/28/2022, resident does not have a diagnosis of Dementia or mild cognitive impairment.

cont on 9099A-C(1)..
Unfounded
Estimated Days of Completion:
SUPERVISOR'S NAME: Maribeth SentyTELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Sabrina CalzadaTELEPHONE: (510) 829-2133
LICENSING EVALUATOR SIGNATURE:

DATE: 09/14/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/14/2022
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 8
Control Number 25-AS-20220504080347
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 520 COHASSET RD., STE. 170
CHICO, CA 95926
FACILITY NAME: OAKMONT OF FAIR OAKS
FACILITY NUMBER: 345002797
VISIT DATE: 09/14/2022
NARRATIVE
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9099A-C(1).. Resident’s care plan was updated on 4/22/22 due to reflect an increase in housekeeping services to once daily and increased pet care to include walks (3) times daily. All service points shown were allocated to housekeeping and pet care and noted that resident uses an assistive device for ambulation.

Resident stated to LPA she was able to get up on her own after about 10 minutes and also "was able to move her legs and arms and had her phone handy" and called staff for assistance and she didn’t need to go out to the Emergency Room as she hurt her back and not her head. Resident requested an ice pack from S2 when she arrived at her room to assess her.

Resident had a subsequent fall on 5/9/22 at approximately 7:07 am. The internal incident report reviewed notes that resident slipped/tripped while ambulating possibly due to clutter on the floor area of the apartment;; however, the report states resident did not believe that was a factor in causing her to fall. Resident was injured on her foot/ankle area and 9-1-1 was called for a further evaluation.

Resident Care Coordinator stated on 6/8/2022 that maintenance staff and care staff have observed resident at times to be walking without an assistive device.

Based on information obtained, it cannot be determined that the resident fell due to neglect on the part of the facility and therefore; LPA finds the allegation to be UNFOUNDED- A finding that the allegations are unfounded means that the allegations are false, could not have happened, and/or is without a reasonable basis.

A copy of this report has been provided to facility. Exit interview conducted.
SUPERVISOR'S NAME: Maribeth SentyTELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Sabrina CalzadaTELEPHONE: (510) 829-2133
LICENSING EVALUATOR SIGNATURE:

DATE: 09/14/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/14/2022
LIC9099 (FAS) - (06/04)
Page: 7 of 8
Control Number 25-AS-20220504080347
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 520 COHASSET RD., STE. 170
CHICO, CA 95926

FACILITY NAME: OAKMONT OF FAIR OAKS
FACILITY NUMBER: 345002797
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/14/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
09/15/2022
Section Cited
CCR
87411(a)
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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. In facilities licensed for sixteen or more, sufficient support staff shall be employed to ensure provision of personal assistance and care as required in Section 87608, Postural Supports. Additional staff shall be employed as necessary to perform office work, cooking, house cleaning, laundering, and maintenance of buildings, equipment and grounds. The licensing agency may require any facility to provide additional staff whenever it determines through documentation that the needs of the particular residents, the extent of services provided, or the physical arrangements of the facility require such additional staff for the provision of adequate services. This requirement is not met as evidenced by:
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Licensee/Administrator agree to conduct an in-service about timely responses to pagers and calls.

Documentation of training agenda/attendees to be provided by 9/30/2022.
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Based on documentation reviewed and interviews conducted, the Licensee did not ensure that staff responded timely to resident's (R1) calls for assistance on the night of 4/20/2022- 4/221/2022 and on 5/10/2022 at 4:42 pm and 5:52 pm, which posed an immediately health and safety risk to residents in care.
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Type B
09/30/2022
Section Cited
HSC
1569.625(b)(1&2)
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§1569.625 Staff training; legislative findings; contents b) (1) The department shall adopt regulations to require staff members of residential care facilities for the elderly who assist residents with personal activities of daily living to receive appropriate training. This training shall consist of 40 hours of training. A staff member shall complete 20 hours, including six hours specific to dementia care, as required by subdivision (a) of Section 1569.626 and four hours specific to postural supports, restricted health conditions, and hospice care, as required by subdivision (a) of Section 1569.696, before working independently with residents. The remaining 20 hours shall include six hours specific to dementia care and shall be completed within the first four weeks of employment. The training coursework may utilize various methods of instruction, including, but not limited to, lectures, instructional videos, and interactive online courses. The additional 16 hours shall be hands-on training.
(2) In addition to paragraph (1), training requirements shall also include an additional 20 hours annually, eight hours of which shall be dementia care training, as required by subdivision (a) of Section 1569.626, and four hours of which shall be specific to postural supports, restricted health conditions, and hospice care, as required by subdivision (a) of Section 1569.696. This training shall be administered on the job, or in a classroom setting, or both, and may include online training. This requirement is not met as evidenced by:
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Licensee/Administrator agree to ensure that all facility staff have current trainings as required by the Health and Safety Code. Documentation of trainings completed to be sent to the Department by 9/30/2022. Facility to coordinate with outside ambulance service to provide First Aid/CPR certifications for any staff that need the training.
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Based on documentation reviewed, the Licensee did not ensure that initial or annual training was current for (3) of (5) staff (S2. S3 and S5) whose records were reviewed on 9/13/2022, which poses a potential health and safety risk to 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: Maribeth SentyTELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Sabrina CalzadaTELEPHONE: (510) 829-2133
LICENSING EVALUATOR SIGNATURE:

DATE: 09/14/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/14/2022
LIC9099 (FAS) - (06/04)
Page: 8 of 8