347003908-9-10-2021-25-AS-MSEY-C6VVKJ-20210915163024

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 347003908
Report Date: 09/10/2021
Date Signed: 09/10/2021 04:39:35 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
08/26/2021 and conducted by Evaluator Angela Hood

COMPLAINT CONTROL NUMBER: 25-AS-20210826163304

FACILITY NAME:	FAIR OAKS CARE HOME AT MONTE PARK		FACILITY NUMBER:	347003908
ADMINISTRATOR:	TOMASIC, ZELKA		FACILITY TYPE:	740
ADDRESS:	8156 MONTE PARK AVENUE		TELEPHONE:	(916) 267-3867
CITY:	FAIR OAKS	STATE: CA	ZIP CODE:	95628
CAPACITY:	5	CENSUS: 1	DATE:	09/10/2021
		UNANNOUNCED	TIME BEGAN:	03:00 PM
MET WITH:	Zelka Tomasic, Administrator		TIME COMPLETED:	04:00 PM

ALLEGATION(S):

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-Staff smoking while oxygen tank are in use.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Angela Hood arrived at the care home today and met with the Administrator, Zelka Tomasic, to deliver findings into the allegation of staff smoking while oxygen tanks are in use. 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 visit conducted on 8/30/21, resident (R1) was not observed to be using oxygen. The facility currently has one resident in care. Interviews conducted with R1 indicated that R1 does not use oxygen and has never needed oxygen. The Centrally Stored Medication and Destruction Record for R1 does not indicate that R1 utilizes oxygen.

Based on interviews conducted and records reviewed, the above allegations are found 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. Exit interview conducted.

Unfounded

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: 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.

LIC9099 (FAS) - (06/04)

Page: 1 of 4

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
08/26/2021 and conducted by Evaluator Angela Hood

COMPLAINT CONTROL NUMBER: 25-AS-20210826163304

FACILITY NAME:	FAIR OAKS CARE HOME AT MONTE PARK		FACILITY NUMBER:	347003908
ADMINISTRATOR:	TOMASIC, ZELKA		FACILITY TYPE:	740
ADDRESS:	8156 MONTE PARK AVENUE		TELEPHONE:	(916) 267-3867
CITY:	FAIR OAKS	STATE: CA	ZIP CODE:	95628
CAPACITY:	5	CENSUS: 1	DATE:	09/10/2021
		UNANNOUNCED	TIME BEGAN:	03:00 PM
MET WITH:	Zelka Tomasic, Administrator		TIME COMPLETED:	04:00 PM

ALLEGATION(S):

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-Staff not wearing mask.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Angela Hood arrived at the care home today and met with the Administrator, Zelka Tomasic, to deliver findings into the allegation of staff not wearing a mask. 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.

Visits were conducted at the care home on 8/30/21 by LPA Melana Llopis and outside agency personnel and the Administrator was not wearing a mask upon entry to the care home. Interview with resident (R1) indicated that the Administrator wears a mask while providing care. However, staff are required to wear masks at all times while in the facility.

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

Substantiated

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: 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.

LIC9099 (FAS) - (06/04)

Page: 2 of 4

Control Number 25-AS-20210826163304

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 CARE HOME AT MONTE PARK	FACILITY NUMBER: 347003908
	VISIT DATE: 09/10/2021

NARRATIVE

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Additional concerns in complaint were addressed in a case management visit conducted on 9/1/21.

Based on interviews conducted, the preponderance of evidence standards have been met. Therefore, the above allegations are found to be SUBSTANTIATED. Per California Code of Regulations, Title 22 Division 6, Chapter 8, deficiencies are being cited on the attached 9099D. Exit interview conducted and a copy of this report was provided to Administrator. Appeal rights were provided.

SUPERVISOR'S NAME: Maribeth Senty	TELEPHONE: (916) 214-0485
LICENSING EVALUATOR NAME: Angela Hood	TELEPHONE: 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

LIC9099 (FAS) - (06/04)

Page: 3 of 4

Control Number 25-AS-20210826163304

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 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 CCR 87468.1(a)(2)	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: (2) To be accorded safe, healthful and comfortable accommodations, furnishings and equipment.	1 2 3 4 5 6 7	Administrator agrees to submit a statement of understanding that masks shall be worn by staff in the care home by the POC due date of 9/24/21.
	8 9 10 11 12 13 14	This requirement was not met as evidenced by: Based on observations, the facility staff was seen not wearing a mask in the care home, which poses a potential health and safety risk to clients in care.	8 9 10 11 12 13 14
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

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) 214-0485
LICENSING EVALUATOR NAME: Angela Hood	TELEPHONE: 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

LIC9099 (FAS) - (06/04)

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