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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 347004533
Report Date: 03/28/2022
Date Signed: 03/28/2022 04:31:24 PM

Substantiated


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
06/24/2021 and conducted by Evaluator Kevin Mknelly
COMPLAINT CONTROL NUMBER: 25-AS-20210624100053
FACILITY NAME:OLIVE OAKS CAREFACILITY NUMBER:
347004533
ADMINISTRATOR:OVIDIU BARBUFACILITY TYPE:
740
ADDRESS:7833 OLIVE STREETTELEPHONE:
(916) 536-0764
CITY:FAIR OAKSSTATE: CAZIP CODE:
95628
CAPACITY:6CENSUS: 1DATE:
03/28/2022
UNANNOUNCEDTIME BEGAN:
03:30 PM
MET WITH:Ana SuiuganTIME COMPLETED:
05:00 PM
ALLEGATION(S):
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Facility did not allow hospice care to be provided to resident.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Kevin Mknelly arrived at the facility unannounced on March 28, 2022 to deliver complaint findings. LPA met with Licensee and explained the purpose of the visit. Prior to initiating the complaint visit, LPA completed required COVID-19 testing protocols, and a daily self-screening questionnaire for symptoms of COVID-19 infection to affirm no COVID-19 related symptoms. LPA completed a facility risk assessment upon arrival. LPA ensured they applied hand sanitizer before entering the facility and the following Personal Protective Equipment (PPE) was worn: Surgical Mask. Additionally, LPA was screened by facility staff upon entering the facility.

The department reviewed client/resident records and conducted extensive interviews.
The department finds that the allegations cited above are substantiated.

Facility did not allow hospice care to be provided to resident. 7/2/21 Licensee- . Administrator stated that the family wanted R1 to be placed on hospice. Administrator stated that at the time she had two
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Maribeth Senty
LICENSING EVALUATOR NAME: Kevin Mknelly
LICENSING EVALUATOR SIGNATURE:

DATE: 03/28/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/28/2022
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 6
Control Number 25-AS-20210624100053
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: OLIVE OAKS CARE
FACILITY NUMBER: 347004533
VISIT DATE: 03/28/2022
NARRATIVE
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residents receiving hospice care. Administrator stated that they suggested one Hospice agency because R1's roommate was already receiving services from them. Administrator stated that she suggested that agency because she wanted to avoid having multiple people coming into the facility, due to COVID.
Administrator stated that she had mentioned to R1's daughters that R1 could have a private room and receive services from the family's preferred hospice agency, however, never received a call back regarding the suggestion.

11/16/21- LPA Angela Hood contacted the preferred hospice agency and spoke with the Clinical Manager (CM). CM stated that she remembers resident (R1). CM stated that Olive Oaks Care initially refused hospice services from the preferred agency.

As a result of this investigation, LPA finds allegation to be (S) Substantiated - A finding that the complaint is Substantiated means that the allegation is valid because the preponderance of the evidence standard has been met. The following deficiencies were cited on 9099-D, per Title 22 Regulations, Division 6. (A)This poses an immediate Health and Safety risk to clients/residents in care. (B) This poses a potential Health and Safety risk, or personal rights violation, to clients/residents in care.

Report reviewed with Licensee . Copy of this report and appeal rights provided.
SUPERVISORS NAME: Maribeth Senty
LICENSING EVALUATOR NAME: Kevin Mknelly
LICENSING EVALUATOR SIGNATURE:

DATE: 03/28/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/28/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 6
Control Number 25-AS-20210624100053
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: OLIVE OAKS CARE
FACILITY NUMBER: 347004533
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/28/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
04/18/2022
Section Cited
CCR
87468.2(a)(18)
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Additional Personal Rights of Residents in Privately Operated Facilities (a)(18) To select their own physicians, pharmacies, privately paid personal assistants, hospice agency,... according to these personal rights.
This requirement was not met as evidenced by
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Licensee will submit a statement of understanding of this requirement to CCL by the POC date of 4/18/22.
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statements and records reviewed found Licensee discouraged one gaency for another that was already active at the home.
This posed a potential violation of the resident's personal rights.
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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.
SUPERVISORS NAME: Maribeth Senty
LICENSING EVALUATOR NAME: Kevin Mknelly
LICENSING EVALUATOR SIGNATURE:

DATE: 03/28/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/28/2022
LIC9099 (FAS) - (06/04)
Page: 3 of 6
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
06/24/2021 and conducted by Evaluator Kevin Mknelly
COMPLAINT CONTROL NUMBER: 25-AS-20210624100053

FACILITY NAME:OLIVE OAKS CAREFACILITY NUMBER:
347004533
ADMINISTRATOR:OVIDIU BARBUFACILITY TYPE:
740
ADDRESS:7833 OLIVE STREETTELEPHONE:
(916) 536-0764
CITY:FAIR OAKSSTATE: CAZIP CODE:
95628
CAPACITY:6CENSUS: 1DATE:
03/28/2022
UNANNOUNCEDTIME BEGAN:
03:30 PM
MET WITH:Ana SuiuganTIME COMPLETED:
05:00 PM
ALLEGATION(S):
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Staff did not follow medical orders.
INVESTIGATION FINDINGS:
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On 3/28/22 , Licensing Program Analyst (LPA) Kevin Mknelly spoke to Licensee of facility. The reason for the visit was to deliver findings for the allegation sited above. Upon entering the facility, analyst spoke with staff to pre-screen that the facility is COVID free. Analyst also self-screened for having no known symptoms or exposure. Analyst followed facility's screening, wore a surgical mask and maintained distance during the visit.

LPA reviewed staff and resident records and conducted extensive interviews.
LPA finds that the allegation cited above are Unsubstantiated.Statements and records reviewed were inconsistent regarding the orders for R1 level of activity and blood pressure precautions.

As a result of this investigation, LPA finds allegation to be (US)Unsubstantiated - A finding that the complaint is Unsubstantiated means that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. Exit interview with administrator.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Maribeth Senty
LICENSING EVALUATOR NAME: Kevin Mknelly
LICENSING EVALUATOR SIGNATURE:

DATE: 03/28/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/28/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 4 of 6
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
06/24/2021 and conducted by Evaluator Kevin Mknelly
COMPLAINT CONTROL NUMBER: 25-AS-20210624100053

FACILITY NAME:OLIVE OAKS CAREFACILITY NUMBER:
347004533
ADMINISTRATOR:OVIDIU BARBUFACILITY TYPE:
740
ADDRESS:7833 OLIVE STREETTELEPHONE:
(916) 536-0764
CITY:FAIR OAKSSTATE: CAZIP CODE:
95628
CAPACITY:6CENSUS: 1DATE:
03/28/2022
UNANNOUNCEDTIME BEGAN:
03:30 PM
MET WITH:Ana SuiuganTIME COMPLETED:
05:00 PM
ALLEGATION(S):
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Staff did not provide 60-day notice prior to increasing the resident's rate.
Facility accepted a resident that required a higher level of care.
Facility did not allow medical care to be provided to resident.
Resident denied visitation from responsible party.
Staff did not seek medical attention for resident in a timely manner.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Kevin Mknelly arrived at the facility unannounced on 3/28/22 to provide complaint findings. LPA met with staff and explained the purpose of the visit. Prior to initiating the visit, LPA completed required COVID-19 testing protocols, and a daily self-screening questionnaire for symptoms of COVID-19 infection to affirm no COVID-19 related symptoms. Upon arrival LPA completed a facility risk assessment. LPA ensured they applied hand sanitizer before entering the facility and the following Personal Protective Equipment (PPE) was worn: Surgical Mask. Additionally, LPA were screened by facility staff upon entering the facility.

LPAs reviewed resident records, facility records and conducted interviews.
The department finds that facility met Tittle 22 requirements.

Regarding the allegation that staff did not provide 60-day notice prior to increasing the resident's rate. 7/2/21 Rp -RP stated that they were quoted $4500/month for R1 to reside at the care home while
Unfounded
Estimated Days of Completion:
SUPERVISORS NAME: Maribeth Senty
LICENSING EVALUATOR NAME: Kevin Mknelly
LICENSING EVALUATOR SIGNATURE:

DATE: 03/28/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/28/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 5 of 6
Control Number 25-AS-20210624100053
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: OLIVE OAKS CARE
FACILITY NUMBER: 347004533
VISIT DATE: 03/28/2022
NARRATIVE
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 they were at a skilled nursing facility. It is alleged that R1 was assessed at another facility and when R1 arrived at the facility, the licensee reassessed the resident to need more care than previously known. The resident's fees were increased before the admission agreement was signed.

Regarding allegation that facility accepted a resident that required a higher level of care. 7/2/21 Rp- RP stated that the care home was providing good care to R1 until they disagreed with R1's POAs on what hospice care should be provided.

Regarding allegation that facility did not allow medical care to be provided to resident. 7/2/21 Rp- RP stated that the allegation that the facility did not allow medical care to be provided was not true. RP stated that there was a doctor going to the facility from home health agency and providing medical care to R1.

regarding allegation that resident denied visitation from responsible party. 7/2/21 Rp- RP stated that they were allowed to visit R1 at the care home.

Regarding the allegation that staff did not seek medical attention for resident in a timely manner. 7/2/21 Rp LPA, Angela Hood, went over allegations with RP and RP stated that the allegation of facility did not seek timely medical attention is not an accurate allegation.

This agency has investigated the above complaint allegations. We have found that the complaint is UNFOUNDED, meaning that the allegation was false, could not have happened and/or is without a reasonable basis. We have therefore dismissed the complaint.

Exit interview conducted and report provided.
SUPERVISORS NAME: Maribeth Senty
LICENSING EVALUATOR NAME: Kevin Mknelly
LICENSING EVALUATOR SIGNATURE:

DATE: 03/28/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/28/2022
LIC9099 (FAS) - (06/04)
Page: 6 of 6