347003219-9-28-2021-25-AS-MSEY-C7DQ6H-20211001115330

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 347003219
Report Date: 09/16/2021
Date Signed: 09/28/2021 01:17:27 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
06/02/2021 and conducted by Evaluator Sabrina Calzada

PUBLIC

COMPLAINT CONTROL NUMBER: 25-AS-20210602145611

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:	0	CENSUS: 0	DATE:	09/16/2021
		UNANNOUNCED	TIME BEGAN:	10:30 AM
MET WITH:	Carolyn Smith, Licensee		TIME COMPLETED:	11:15 AM

ALLEGATION(S):

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Facility did not allow medical care to be given to resident
Insufficient staffing resulted in staff not adequately observing resident's change in condition
Facility did not notify resident's physician or responsible party regarding resident's change in condition
Insufficient staffing at night

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Sabrina Calzada contacted Licensee, Carolyn Smith, by phone on 9/16/2021, and explained the reason for the phone call was to deliver investigative compalint findings. Findings are being delivered by phone due to the facility currently being closed.

During the course of the investigation, LPA reviewed documentation pertinent to resident (R1) including, but not limited to, resident's physician's report, care plan, charting notes, Unusual Incident/Injury Report (LIC624) and the 9-1-1 incident report. LPA interviewed the Licensee, a caregiver staff (S1) and a local fire department representative. The Administrator at the time was not able to be contacted by phone. The results of the investigation are as follows:

Allegation: Facility did not allow medical care to be given to resident.

Complaint information received indicates that resident's family member visited her through the window, due to Covid-19 precautionary measures in place, on 12/22/2020 and observed resident to have had a change in condition, as she would not look at the family member and appeared unable to focus. Resident stated and resident's charting notes indicate that these concerns were brought to the attention of the facility Administrator, inquiring if resident had a temperature. Temperature check notes dated 12/22/2020 note that resident's temperature was recorded as 95.7*F.

cont on 9099C(1)...

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Maribeth Senty	TELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Sabrina Calzada	TELEPHONE: (510) 829-2133
LICENSING EVALUATOR SIGNATURE:	DATE: 09/15/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/15/2021

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 7

Control Number 25-AS-20210602145611

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: 09/16/2021

NARRATIVE

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9099C(1) Resident's family member stated she visited resident again, through the window, on 12/23/2020, and resident appeared to be in a worse condition and would not open her eyes. Resident charting notes, dated 12/23/2020, document that resident's family member visited again and expressed concern that resident appeared sick and to have a fever. Temperature logs indicate that resident's temperature was recorded at 95.3*F on 12/23/2020. Resident's family member stated she wanted to contact 9-1-1 regarding her mother's change in condition, but was told by the Administrator that resident would not be able to return if she leaves the facility. Resident's family member stated she again went to visit resident on 12/24/2020 and observed that resident's condition had not improved from the day before, so she contacted 9-1-1, observing resident through the window. Resident charting notes, dated 12/24/2020, document that resident wanted to sleep but did eat that day and had a temperature of 98.2*F. Interviews conducted with the Licensee, Administrator and staff (S1) indicated that resident was not exhibit any change in condition or symptoms of Covid that would prompt staff to contact emergency medical services.

Resident's family member stated that facility staff refused to allow emergency medical services to enter the facility until the Licensee was notified of their presence. 9-1-1 Incident Report, from 12/24/2020 (16:57), states that facility staff would not let emergency crew enter until staff talked with the facility owner, who "was not okay" with them being on-site, expressing concerns about the resident being transported out and returning to the facility during the Covid pandemic. 9-1-1 Incident Report further documents that once resident was assessed and found to have high blood sugar, emergency crew communicated to staff that they would like to transport resident and staff requested that they contact resident's Power of Attorney (POA) first. The 9-1-1 report states that the emergency crew contacted resident's POA, who stated the same concerns about resident leaving and then possibly returning with Covid. POA was advised to contact resident's health care help line who advised the POA to allow resident to be transported. 9-1-1 report reads that facility staff tried to stop the emergency medical crew from taking resident out of the building until they were able to speak with the POA, who did agree to transport resident once called. The department was provided with a copy of the notice posted at the entrance stating "Medical Personnel" were allowed to visit during Covid-19 Restrictions.

Based on information obtained, LPA finds the allegation "Facility did not allow medical care to be given to resident" to be SUBSTANTIATED-

cont on 9099C(2)...

SUPERVISOR'S NAME: Maribeth Senty	TELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Sabrina Calzada	TELEPHONE: (510) 829-2133
LICENSING EVALUATOR SIGNATURE:	DATE: 09/16/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/16/2021

LIC9099 (FAS) - (06/04)

Page: 2 of 7

Control Number 25-AS-20210602145611

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: 09/16/2021

NARRATIVE

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9099C(2). Allegation: Insufficient staffing resulted in staff not adequately observing resident's change in condition: Complaint alleges that resident's change in condition, including being hospitalized for high blood sugar and a Urinary Tract Infection (UTI), and a decline in eating and drinking were not observed by staff due to insufficient staffing.

Resident moved to facility on/around July 2019. Physician's Report, dated 6/18/2019, does not indicate that resident has motor impairment/ paralysis. Care plan, dated 7/1/2020, does not indicate that resident needs a mobility device. Resident's family member stated that resident did not use a mobility device and could walk independently on prior visits, and was not seen in a wheelchair until 12/22/2020. When asked, staff (S1) stated resident could walk, if staff held on to her. Interview with Administrator revealed that resident did not have a walker or wheelchair prior to being hospitalized and resident had a chair in her bedroom to use for window visits unless the visit was conducted at the activity room window. Staff (S1) stated that resident "had no change in condition - she was a little weaker but was still able to walk at that point and we helped walked her to the chair", explaining that "(R1) was tired from her shower" on 12/24/2020. Administrator stated that besides R1 "being a little slower than usual, resident did not have a change in condition and resident ate good, had no fever and that she dressed resident the morning on 12/24/2020 when she was transported to the hospital. Resident's family member stated that resident continued to decline on 12/23/2020 and by 12/24/2020 when she visited again, resident was "non-responsive" and sitting in the wheelchair like a "wet noddle". Resident's family member stated she was informed by the ER doctor that resident's blood sugar was 433, her sodium level was 166 and resident was dehydrated as she had not been eating and drinking and also had a UTI. Hospital Medical records were not available for review; however, 9-1-1 report, dated 12/24/2020 (16:57), notes that resident was assessed and determined to have high blood sugar and was transported to the emergency room.

On 12/7/2020, the facility reported a positive Covid case for a staff who tested on 11/29/2020 and received results on 12/3/2020. On 12/9/2020, (8) residents and (7) staff were tested, and on 12/10/2020, (2) residents received positive results, requiring additional staff for 14 days, through 12/24/2020. Notes from 12/11/2020- 12/17/2020 indicate that (2) positive residents were asymptomatic and the remaining (6) residents and staff did not have any Covid symptoms. On 12/22/2020, Licensee indicated that an additional staff member was quarantining at home due to a low grade fever. On 12/23/2020 (13:00), (6) staff and (6) residents were tested, including resident (R1), and results were processed on 12/24/2020(11:17 am) and positive results reported to the facility on 12/24/2020 for (2) residents and (1) staff. Licensee stated that "the results had not been received by 12/24/2020 when the paramedics came". Department notes show that Licensee reported on 12/29/2020, that positive results were received on 12/24/2020.

cont on 9099C(3)....

SUPERVISOR'S NAME: Maribeth Senty	TELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Sabrina Calzada	TELEPHONE: (510) 829-2133
LICENSING EVALUATOR SIGNATURE:	DATE: 09/16/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/16/2021

LIC9099 (FAS) - (06/04)

Page: 3 of 7

Control Number 25-AS-20210602145611

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: 09/16/2021

NARRATIVE

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9099C(3)...Per local public health and department guidance, additional, designated staffing is required to care for positive residents. Interviews revealed that there was (1) staff a the facility when 911 arrived at 16:57, and the 9-1-1- incident report references (1) female staff present. Administrator stated in an interview that she was not present at the facility on 12/24/2020 when 9-1-1- arrived and 9-1-1 report documents that the owner/Licensee was contacted by phone upon arrival.

Based on information obtained, LPA finds the allegation "Insufficient staffing resulted in staff not adequately observing resident's change in condition" to be SUBSTANTIATED.

Allegation: Facility did not notify resident's physician or responsible party regarding resident's change in condition. Resident's family member stated that resident was hospitalized for high blood sugar, a UTI and was told by hospital personnel that resident had not been eating or drinking. Resident's family member stated that resident was in a wheelchair during the visits from 12/22/2020- 12/24/2020 and did not use a wheelchair prior to these visits and resident's physician was not notified .

Resident charting notes dated 12/24/2020 note that resident "wanted to sleep today" and did eat some oatmeal and 6 oz juice and took medications. Temp was 98.2 at 8:15 am. Additional notes from 12/24/2020 (13:30) document that Licensee talked to resident's POA and informed him of the vitals. Another entry on 12/24/2020 note that "resident is still sleeping". A subsequent entry on 12/24/2020 states that resident was admitted to the hospital for high blood sugar and high sodium and was placed in the Intensive Care Unit (ICU) due to testing positive for Covid.

There is no documentation that resident's physician or POA was notified of resident using a wheelchair from 12/22/2020 through 12/24/2020 or that resident was noted to have been sleeping for much of the day on 12/24/2020. Resident's family member stated that Administrator called the POA on 12/23/2020 and said resident was fine and eating well. LIC624 completed following resident being sent out on 12/24/2020 and 9-1-1 both document that resident's POA contacted resident's physician prior to resident being sent to the ER. Resident passed on 4/10/2021 and the county death certificate notes that the causes of death are: Failure to Thrive and Alzheimer's Dementia.

Based on information obtained, LPA finds the allegation "Facility did not notify resident's physician or responsible party regarding resident's change in condition" to be SUBSTANTIATED.
cont on 9099C(4)...

SUPERVISOR'S NAME: Maribeth Senty	TELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Sabrina Calzada	TELEPHONE: (510) 829-2133
LICENSING EVALUATOR SIGNATURE:	DATE: 09/16/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/16/2021

LIC9099 (FAS) - (06/04)

Page: 4 of 7

Control Number 25-AS-20210602145611

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: 09/16/2021

NARRATIVE

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9099C(4)....Allegation: Insufficient staffing at night.
Facility provided care to residents diagnosed with Dementia. Physician's report dated dated 6/18/2019 shows that resident (R1) had a diagnosis of Dementia but did not wander; however, resident had a change in condition on/around 12/22/2020, utilizing a wheelchair, when she previously was able to walk without the use of a mobility device. Resident (R1) was tested on 12/23/2020 and received a positive test result on 12/24/2020, after being sent out to the Emergency Room.

Department notes reviewed show that on 12/9/2020, there were (8) residents and (7) staff who were tested, and on 12/10/2020, (2) residents received positive results, requiring additional staff for 14 days, through 12/24/2020. Notes from 12/11/2020- 12/17/2020 indicate that (2) positive residents were asymptomatic and the remaining (6) residents and staff did not have any Covid symptoms. On 12/22/2020, Licensee indicated that an additional staff member was quarantining at home due to a low grade fever. On 12/23/2020 (13:00), (6) staff and (6) residents were tested, including resident (R1), and positive results reported to the facility on 12/24/2020 for (2) residents and (1) staff. Licensee stated that "the results had not been received by 12/24/2020 when the paramedics came".

Per local public health and department guidance, additional, designated staffing is required to care for positive residents during all shifts. Staff (S1) stated that the facility always had awake NOC staff. Staffing schedules were not available. Department notes from Covid phone calls made do not indicate that staffing was increased once there were Covid positive residents. Given the change in condition with resident (R1), who has Dementia, and multiple positive Covid cases in December 2020, staffing should have been increased based on the increased care needs of the residents. There was no documentation provided that staffing was increased during the month of December 2020.

Based on information obtained, LPA finds the allegation to be SUBSTANTIATED.

Based on information obtained and evaluated, LPA finds the (4) allegations 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 (4) deficiencies are cited on the 9099D page.

Exit interview. Copy of report emailed to Licensee to sign/return by COB 9/16/2021.

SUPERVISOR'S NAME: Maribeth Senty	TELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Sabrina Calzada	TELEPHONE: (510) 829-2133
LICENSING EVALUATOR SIGNATURE:	DATE: 09/16/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/16/2021

LIC9099 (FAS) - (06/04)

Page: 5 of 7

Control Number 25-AS-20210602145611

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
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 09/16/2021

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Request Denied Type A 09/17/2021 Section Cited CCR 87465(g)	1 2 3 4 5 6 7	87465 Incidental Medical and Dental Care (g) The licensee shall immediately telephone 9-1-1 if an injury or other circumstance has resulted in an imminent threat to a resident’s health including, but not limited to, an apparent life-threatening medical crisis except as specified in Sections This requirement is not met as evidenced by:	1 2 3 4 5 6 7	Licensee to state how she will correct this violation.
	8 9 10 11 12 13 14	Based on interviews conducted and documentation reviewed, the Licensee did not ensure that resident (R1) received emergency medical care on 12/24/2020 by calling 9-1-1 and when resident's family member called 9-1-1, emergency medical crew was not allowed to enter the facility until speaking with the Licensee, which posed an immediate health and safety risk to resident in care.	8 9 10 11 12 13 14
Request Denied Type A 09/17/2021 Section Cited CCR 87411(a)	1 2 3 4 5 6 7	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. This requirement is not met as evidenced by:	1 2 3 4 5 6 7	Licensee to state how she will correct this violation.
	8 9 10 11 12 13 14	Based on interviews conducted and documentation reviewed, the Licensee did not ensure that there was sufficient staffing to observe resident's (R1) change in condition from 12/22/2020- 12/24/2020, which posed an immediate health and safety risk to resident in care.	8 9 10 11 12 13 14

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 Senty	TELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Sabrina Calzada	TELEPHONE: (510) 829-2133
LICENSING EVALUATOR SIGNATURE:	DATE: 09/16/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/16/2021

LIC9099 (FAS) - (06/04)

Page: 6 of 7

Control Number 25-AS-20210602145611

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
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 09/16/2021

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Request Denied Type A 09/17/2021 Section Cited CCR 87466	1 2 3 4 5 6 7	87466 Observation of the Resident The licensee shall ensure that residents are regularly observed for changes in physical, mental, emotional and social functioning and that appropriate assistance is provided when such observation reveals unmet needs. When changes such as unusual weight gains or losses or deterioration of mental ability or a physical health condition are observed, the licensee shall ensure that such changes are documented and brought to the attention of the resident's physician and the resident's responsible person, if any. This requirement is not met as evidenced by:	1 2 3 4 5 6 7	LIcensee to state how she will correct this violation.
	8 9 10 11 12 13 14	Based on documentation reviewed and interviews conducted, the Licensee did not ensure that resident's (R1) change in condition from 12/22/2020- 12/24/2020, including the use of a wheelchair and sleeping more, were timely brought to the attention of resident's physician and family member, which posed an immediate health and safety risk to resident in care.	8 9 10 11 12 13 14
Request Denied Type A 09/17/2021 Section Cited CCR 87705(c)(4)(A)	1 2 3 4 5 6 7	87705 Care of Persons with Dementia (c) Licensees who accept and retain residents with dementia shall be responsible for ensuring the following: (4) There is an adequate number of direct care staff to support each resident’s physical, social, emotional, safety and health care needs as identified in his/her current appraisal. (A) In addition to requirements specified in Section 87415, Night Supervision, a facility with fewer than 16 residents shall have at least one night staff person awake and on duty if any resident with dementia is determined through a pre-admission appraisal, reappraisal or observation to require awake night supervision. This requirement is not met as evidenced by:	1 2 3 4 5 6 7	LIcensee to state how she will correct this violation.
	8 9 10 11 12 13 14	Based on interviews conducted and documentation reviewed, the Licensee did not ensure that there was sufficient staffing at night to observe resident (R1) who had a diagnosis of Dementia and a change in condition from 12/22/2020- 12/24/2020 and other residents who had tested positive for Covid, on 12/09/2020 and on 12/23/2020, which posed an immediate health and safety risk to residents in care.	8 9 10 11 12 13 14

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 Senty	TELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Sabrina Calzada	TELEPHONE: (510) 829-2133
LICENSING EVALUATOR SIGNATURE:	DATE: 09/16/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/16/2021

LIC9099 (FAS) - (06/04)

Page: 7 of 7