347003908-10-6-2021-25-AS-MSEY-C7KNPA-20211007103758

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 347003908
Report Date: 10/06/2021
Date Signed: 10/06/2021 12:33:26 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
09/04/2021 and conducted by Evaluator Angela Hood

COMPLAINT CONTROL NUMBER: 25-AS-20210904104134

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:	10/06/2021
		UNANNOUNCED	TIME BEGAN:	11:20 AM
MET WITH:	Zelka Tomasic, Administrator		TIME COMPLETED:	12:45 PM

ALLEGATION(S):

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-Licensee has adults that are not criminal record cleared living in the care home

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Angela Hood arrived at the care home today and met with Zelka Tomasic, Administrator, to deliver findings into the allegation that licensee has adults that are not criminal record cleared living in the care home. Facility currently does not have any COVID-19 positive cases. LPA wore a N95 mask and was screened by facility upon entry. Facility staff wore a mask in the care home.

During the course of the investigation, LPA conducted visits on 9/10/21 and 10/6/21 touring 4 bedrooms and 2 bathrooms, the exterior of the home, and the garage. During both visits to the care home LPA observed 1 resident (R1) sitting in the living room watching television. LPA also conducted interviews with the Administrator and R1. Interviews indicated that no other adults are residing at the care home. LPA reveiwed documentation for both adults that were previously residing at the care home, one adult recieived criminal record clearance, and the other is going through the criminal record clearance process.

Based on interviews conducted and observation, although the allegations may have happened or are valid,
there is not a preponderance of evidence to prove the alleged violations did or did not occur. Therefore, the
allegation is UNSUBSTANTIATED. No deficiencies are being cited during this visit. Exit interview conducted.

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: 09/29/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/29/2021

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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