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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 347003908
Report Date: 09/10/2021
Date Signed: 09/10/2021 04:42:49 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 520 COHASSET RD., STE. 170
CHICO, CA 95926
FACILITY NAME:FAIR OAKS CARE HOME AT MONTE PARKFACILITY NUMBER:
347003908
ADMINISTRATOR:TOMASIC, ZELKAFACILITY TYPE:
740
ADDRESS:8156 MONTE PARK AVENUETELEPHONE:
(916) 267-3867
CITY:FAIR OAKSSTATE: CAZIP CODE:
95628
CAPACITY:5CENSUS: 1DATE:
09/10/2021
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
04:00 PM
MET WITH:Zelka Tomasic, AdministratorTIME COMPLETED:
04:15 PM
NARRATIVE
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Licensing Program Analyst (LPA) Angela Hood arrived at the care home today and met with the Administrator, Zelka Tomasic, to conduct a case management visit. LPA wore a N95 mask and was screened upon entry in the care home. Staff wore a mask in the care home. There are no COVID positive cases at the facility.

During a file review, it was discovered that resident (R1’s) Physician’s Report LIC602A was dated 12/7/2019 and R1 has a diagnosis of Dementia. Each resident with dementia shall have a medical assessment conducted annually. The facility was unable to provide an updated LIC602A.

Due to the information above, per California Code of Regulations, Title 22 Division 6, Chapter 8, deficiencies are being cited on the attached 809-D page.



Exit interview was conducted. A copy of this report and appeal rights provided.
SUPERVISOR'S NAME: Maribeth SentyTELEPHONE: (916) 214-0485
LICENSING EVALUATOR NAME: Angela HoodTELEPHONE: 650-676-0390
LICENSING EVALUATOR SIGNATURE:

DATE: 09/10/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/10/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC809 (FAS) - (06/04)
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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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 CARE HOME AT MONTE PARK
FACILITY NUMBER: 347003908
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/10/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/24/2021
Section Cited

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87705 Care of Persons with Dementia (c) Licensees who accept and retain residents with dementia shall be responsible for ensuring the following: (5) Each resident with dementia shall have an annual medical assessment as specified in Section 87458, Medical Assessment, and a reappraisal done at least annually, both of which shall include a reassessment of the resident’s dementia care needs.
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This requirement is not met as evidenced by:
Based on records reviewed, the facility did not ensure resident (R1) had an updated medical assessment conducted on an annual basis, which posed a potential health, safety, and personal rights 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) 214-0485
LICENSING EVALUATOR NAME: Angela HoodTELEPHONE: 650-676-0390
LICENSING EVALUATOR SIGNATURE:
DATE: 09/10/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/10/2021
LIC809 (FAS) - (06/04)
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