347005427-9-14-2022-25-AS-LMUZ-CJJVVH-20220923164623

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 347005427
Report Date: 09/14/2022
Date Signed: 09/14/2022 12:55:28 PM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CHICO - RESIDENTIAL, 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
04/25/2022 and conducted by Evaluator Lavinia Muscan

COMPLAINT CONTROL NUMBER: 25-AS-20220425104727

FACILITY NAME:	OAKMONT OF FOLSOM		FACILITY NUMBER:	347005427
ADMINISTRATOR:	POUYA ANSARI		FACILITY TYPE:	740
ADDRESS:	1574 CREEKSIDE DR		TELEPHONE:	(916) 817-4500
CITY:	FOLSOM	STATE: CA	ZIP CODE:	95630
CAPACITY:	88	CENSUS: 74	DATE:	09/14/2022
		UNANNOUNCED	TIME BEGAN:	12:20 PM
MET WITH:	Michael Clymo, Administrator		TIME COMPLETED:	01:15 PM

ALLEGATION(S):

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Facility has an outbreak.
Facility failed to provide a safe and comfortable environment.
Facility is unsanitary.

INVESTIGATION FINDINGS:

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On 9/14/2022, Licensing Program Analysts (LPA) Lavinia Muscan arrived at the facility unannounced to deliver complaint findings into the allegations listed above and met with Administrator, Michael Clymo. Prior to 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 ensured hand sanitizer was applied before entering the facility and the following Personal Protective Equipment (PPE) was worn: surgical mask.

During the investigation, the Department conducted interviews and reviewed documentation pertinent to the investigation.

The results of the investigation are as follows:

**Report continued on 9099-C**

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Laura Munoz	TELEPHONE: (916) 263-4743
LICENSING EVALUATOR NAME: Lavinia Muscan	TELEPHONE: 916-263-4700
LICENSING EVALUATOR SIGNATURE:	DATE: 09/14/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/14/2022

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 4

Control Number 25-AS-20220425104727

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CHICO - RESIDENTIAL, 520 COHASSET RD., STE. 170
CHICO, CA 95926

FACILITY NAME: OAKMONT OF FOLSOM	FACILITY NUMBER: 347005427
	VISIT DATE: 09/14/2022

NARRATIVE

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Facility has an outbreak.
Based on record reviewed, approximately 10 residents within a 2-week span had GI illness symptoms. Interviews with the Executive Director and documentations indicate the facility contacted Local Public Health (LPH) on 4/25/2022 regarding GI outbreak at the facility. LPH informed the Executive Director that based on the information provided, the GI illness in the facility is not considered an outbreak and therefore does not have to be reported. This agency has investigated the above listed allegation (Facility has an outbreak). Although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred therefore, we have found the allegation (Facility has an outbreak) to be UNSUBSTANTIATED.

Exit interview was conducted with Administrator, Michael Clymo, and a copy of this report was provided to the facility. The signature of Administrator on these forms acknowledges receipt of these documents.

SUPERVISOR'S NAME: Laura Munoz	TELEPHONE: (916) 263-4743
LICENSING EVALUATOR NAME: Lavinia Muscan	TELEPHONE: 916-263-4700
LICENSING EVALUATOR SIGNATURE:	DATE: 09/14/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/14/2022

LIC9099 (FAS) - (06/04)

Page: 2 of 4

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CHICO - RESIDENTIAL, 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
04/25/2022 and conducted by Evaluator Lavinia Muscan

COMPLAINT CONTROL NUMBER: 25-AS-20220425104727

FACILITY NAME:	OAKMONT OF FOLSOM		FACILITY NUMBER:	347005427
ADMINISTRATOR:	POUYA ANSARI		FACILITY TYPE:	740
ADDRESS:	1574 CREEKSIDE DR		TELEPHONE:	(916) 817-4500
CITY:	FOLSOM	STATE: CA	ZIP CODE:	95630
CAPACITY:	88	CENSUS: 74	DATE:	09/14/2022
		UNANNOUNCED	TIME BEGAN:	12:20 PM
MET WITH:	Michael Clymo, Administrator		TIME COMPLETED:	01:15 PM

ALLEGATION(S):

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9

Facility has an outbreak.
Facility failed to provide a safe and comfortable environment.
Facility is unsanitary.

INVESTIGATION FINDINGS:

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Unfounded

Estimated Days of Completion:

SUPERVISOR'S NAME: Laura Munoz	TELEPHONE: (916) 263-4743
LICENSING EVALUATOR NAME: Lavinia Muscan	TELEPHONE: 916-263-4700
LICENSING EVALUATOR SIGNATURE:	DATE: 09/14/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/14/2022

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

LIC9099 (FAS) - (06/04)

Page: 3 of 4

Control Number 25-AS-20220425104727

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CHICO - RESIDENTIAL, 520 COHASSET RD., STE. 170
CHICO, CA 95926

FACILITY NAME: OAKMONT OF FOLSOM	FACILITY NUMBER: 347005427
	VISIT DATE: 09/14/2022

NARRATIVE

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Facility failed to provide a safe and comfortable environment.
Interviews with 4 Residents and 4 Staff members state that staff check on residents as needed, provide assistance with ADLs and other needs as required. Resident interviews did not indicate that resident’s feel unsafe or that their needs are not being met. This agency has investigated the complaint alleging (Facility failed to provide a safe and comfortable environment). We have found the complaint was UNFOUNDED, meaning that the allegation is false, could not have happened, and/or is without a reasonable basis.

Facility is unsanitary.
A tour of the facility was conducted, including common areas, resident rooms, dining area and kitchen. LPA did not observe any unsanitary practices at the time of the facility inspection. Training records were obtained and reviewed that indicated facility kitchen staff are meeting training hours and topics as required. In addition, interviews with 4 residents indicated that facility staff clean the facility daily including disinfecting. This agency has investigated the complaint alleging (Facility is unsanitary). We have found the complaint was UNFOUNDED, meaning that the allegation is false, could not have happened, and/or is without a reasonable basis.

Exit interview was conducted with Administrator, Michael Clymo and a copy of this report was provided to the facility. The signature of Administrator on these forms acknowledges receipt of these documents.

SUPERVISOR'S NAME: Laura Munoz	TELEPHONE: (916) 263-4743
LICENSING EVALUATOR NAME: Lavinia Muscan	TELEPHONE: 916-263-4700
LICENSING EVALUATOR SIGNATURE:	DATE: 09/14/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/14/2022

LIC9099 (FAS) - (06/04)

Page: 4 of 4