347003219-5-18-2021-27-AS-MSEY-C37P9L-20210520110717

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 347003219
Report Date: 05/18/2021
Date Signed: 05/18/2021 04:06:58 PM

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
12/28/2020 and conducted by Evaluator Angela Hood

COMPLAINT CONTROL NUMBER: 27-AS-20201228092339

FACILITY NAME:	FAIR OAKS COMMUNITY AT SUNSET		FACILITY NUMBER:	347003219
ADMINISTRATOR:	CAROLYN SMITH		FACILITY TYPE:	740
ADDRESS:	7710 SUNSET AVENUE		TELEPHONE:	(916) 962-7108
CITY:	FAIR OAKS	STATE: CA	ZIP CODE:	95628
CAPACITY:	15	CENSUS: 0	DATE:	05/18/2021
		UNANNOUNCED	TIME BEGAN:	03:00 PM
MET WITH:	Carolyn Smith, Licensee		TIME COMPLETED:	04:20 PM

ALLEGATION(S):

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-Staff did not seek timely medical care for resident resulting in hospitalization.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Angela Hood arrived at the care home today and met with Licensee, Carolyn Smith, to deliver findings into the allegation of staff did not seek timely medical care for resident resulting in hospitalization. Facility currently does not have any COVID-19 positive cases. LPA wore N95 mask and was screened by facility upon entry. Facility staff wore masks in the care home.

During the course of the investigation, LPA conducted interviews and obtained documentation pertinent to the investigation. Interviews with the Administrator, Licensee, and staff (S1) indicated that resident (R1) was transported to the hospital on 12/24/20 after a family member of R1 had contacted emergency services. Care Provider Notes for December 2020 indicate that on 12/22/20, a family member visited R1 and after visit contacted the care home to find out if R1 had a temperature, and the facility notes indicated that R1 did not have a fever. Temperature check notes dated 12/22/20 indicate that R1’s temperature was 95.7 degrees F. Care Provider Notes dated 12/23/20 indicate that R1’s family member visited and expressed that R1 looked sick with a fever.
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Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Maribeth Senty	TELEPHONE: (916) 214-0485
LICENSING EVALUATOR NAME: Angela Hood	TELEPHONE: 650-676-0390
LICENSING EVALUATOR SIGNATURE:	DATE: 05/18/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/18/2021

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 3

Control Number 27-AS-20201228092339

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: FAIR OAKS COMMUNITY AT SUNSET	FACILITY NUMBER: 347003219
	VISIT DATE: 05/18/2021

NARRATIVE

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Temperature check notes dated 12/23/20 indicate that R1’s temperature was 95.3 degrees F. Care Provider Notes dated 12/24/20 indicate that R1 wanted to sleep, however, did eat that day and have a temperature of 98.2 degrees F. Prior to hospitalization, interviews with Administrator, Licensee, and S1 indicated that R1 was not showing any health concerns or signs and symptoms of COVID-19 that would initiate staff at the care home to contact emergency services.

At the time emergency services was contacted for R1, the facility had COVID-19 positives, however, R1 had a negative test result prior to hospitalization. On 12/9/20, R1 had received COVID-19 testing from Sacramento County Public Health, on 12/10/20 negative results were printed by Sacramento County Public Health, and the facility was notified by phone on 12/11/20. R1 was retested during another round of testing conducted by Sacramento County Public Health on 12/23/20 and the facility received positive results for R1 by email on 1/4/21. LPA had been in communication with the Licensee since 12/7/20 regarding the COVID-19 outbreak to ensure facility was following CDC, Local Public Health, and CCLD guidelines.

Upon admission to Kaiser Roseville on 12/24/20, R1 was tested for COVID-19 and facility was notified that R1 had a positive COVID-19 test result. Interviews with Administrator, Licensee, and S1 indicated that R1 exhibited no signs or symptoms of COVID-19 prior to hospitalization and while in the hospital. Interviews with Administrator, Licensee, S1, and R1’s Power of Attorney (POA) indicated that R1 had diabetes, however, there were no physician’s orders authorizing the facility to check or monitor blood sugar through testing. According to a Kaiser Permanente after visit summary dated 7/11/18 and the facility’s MAR for December 2020, R1 took Glipizide 10 mg tablets twice daily to maintain blood glucose levels. Interviews indicated that R1 was being treated at the hospital for high blood sugar and the hospital was trying to stabilize R1’s blood sugar levels. Interview with R1’s POA indicated that the hospital was having a hard time keeping R1’s blood sugar stable. Interview with POA indicated that upon admission to Kaiser Roseville, R1 was tested for a UTI, which came back negative. Interview with POA

*********************************Continued on LIC9099-C**********************************

SUPERVISOR'S NAME: Maribeth Senty	TELEPHONE: (916) 214-0485
LICENSING EVALUATOR NAME: Angela Hood	TELEPHONE: 650-676-0390
LICENSING EVALUATOR SIGNATURE:	DATE: 05/18/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/18/2021

LIC9099 (FAS) - (06/04)

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Control Number 27-AS-20201228092339

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: FAIR OAKS COMMUNITY AT SUNSET	FACILITY NUMBER: 347003219
	VISIT DATE: 05/18/2021

NARRATIVE

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indicated that approximately 2-3 days after admission R1 was retested for a UTI, which came back positive. Interviews with Administrator, Licensee, and R1’s POA indicated that R1 was taking a medication, Cephalexin 500 mg, once per day to prevent UTIs. This medication is also listed on the Kaiser Permanente after visit summary dated 7/11/18 and the facility’s MAR for December 2020.

Based on documentation reviewed and interviews conducted, although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED. No deficiencies are being cited during this visit.

Exit interview conducted.

SUPERVISOR'S NAME: Maribeth Senty	TELEPHONE: (916) 214-0485
LICENSING EVALUATOR NAME: Angela Hood	TELEPHONE: 650-676-0390
LICENSING EVALUATOR SIGNATURE:	DATE: 05/18/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/18/2021

LIC9099 (FAS) - (06/04)

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