347005427-10-21-2022-25-AS-LMUZ-CL7SV2-20221115131157

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 347005427
Report Date: 10/21/2022
Date Signed: 10/21/2022 12:15:21 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
03/23/2022 and conducted by Evaluator Lavinia Muscan

COMPLAINT CONTROL NUMBER: 25-AS-20220323084710

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: 73	DATE:	10/21/2022
		UNANNOUNCED	TIME BEGAN:	11:05 AM
MET WITH:	Administrator, Michael Clymo		TIME COMPLETED:	11:30 AM

ALLEGATION(S):

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Resident sustained unexplained fractures while in care.
Resident sustained unexplained bruising while in care.

INVESTIGATION FINDINGS:

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On 10/21/2022, 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: 10/21/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/21/2022

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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Control Number 25-AS-20220323084710

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: 10/21/2022

NARRATIVE

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Resident sustained unexplained fractures while in care.
Resident sustained unexplained bruising while in care.
On 3/13/22, at approximately 7:00PM-8:00PM hours, facility care staff discovered dark, purple bruises on R1’s right shoulder, arm and chest while assisting with ADLs. R1 did not complain of pain and did not appear to be in pain. Staff interviews indicated staff are not aware how R1 sustained bruising. On 3/15/22, R1’s family was notified, and R1 was taken to a doctor’s appointment on 3/17/22. Medical records show X-Rays were taken, and R1 sustained two rib fractures of the seventh and eighth ribs, and a torn rotator cuff. Medical records noted the fractures were of indeterminate age. Facility staff was interviewed, and none of the staff had information on how R1 sustained injuries. According to staff, R1 is non-ambulatory and would not be able to get up by herself if sustained a fall. Physician Assistant (PA) who treated R1 was interviewed and indicated based on her medical opinion, there is no way to say how old the fractures were. PA stated it is possible the fractures were old and unrelated to the bruises. R1’s x-rays further indicated R1 has old compression fractures in her spine, which are caused from either severe trauma or Osteopenia. Documents reviewed indicated R1 has Osteopenia which affects bone density. Records indicate R1’s bone density is poor and is at a high fracture risk. This agency has investigated the above listed allegations. 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 to be UNSUBSTANTIATED.

Exit interview was conducted with Administrator 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: 10/21/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/21/2022

LIC9099 (FAS) - (06/04)

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