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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 345002797
Report Date: 01/03/2025
Date Signed: 01/03/2025 02:42:41 PM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
This is an official report of an unannounced visit/investigation of a complaint received in our office on
11/05/2024 and conducted by Evaluator Michael Hood
COMPLAINT CONTROL NUMBER: 59-AS-20241105152831
FACILITY NAME:OAKMONT OF FAIR OAKSFACILITY NUMBER:
345002797
ADMINISTRATOR:POUYA ANSARIFACILITY TYPE:
740
ADDRESS:8484 MADISON AVE.TELEPHONE:
(916) 633-1001
CITY:FAIR OAKSSTATE: CAZIP CODE:
95628
CAPACITY:128CENSUS: 86DATE:
01/03/2025
UNANNOUNCEDTIME BEGAN:
11:30 AM
MET WITH:Pouya Ansari, Executive Director (ED)TIME COMPLETED:
02:50 PM
ALLEGATION(S):
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Facility staff are not assisting resident with oxygen
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Michael Hood arrived at the facility and met with Executive Director (ED), Pouya Ansari, to deliver findings into the complaint allegation listed above.

During the course of the investigation, LPA toured the facility, conducted interviews, and reviewed documentation pertinent to the investigation.

The results of the investigation are as follows:

Allegation: Facility staff are not assisting resident with oxygen

** Report continued on 9099-C **
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Anthony Perez
LICENSING EVALUATOR NAME: Michael Hood
LICENSING EVALUATOR SIGNATURE:

DATE: 01/03/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/03/2025
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 2
Control Number 59-AS-20241105152831
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME: OAKMONT OF FAIR OAKS
FACILITY NUMBER: 345002797
VISIT DATE: 01/03/2025
NARRATIVE
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Relevant party reported that facility staff are not ensuring that resident (R1's) portable oxygen is charged and operable for when R1 is ambulating throughout the facility. LPA observed an After Visit Summary from an Emergency Room visit for R1 dated 10/21/2024 which states "please administer oxygen 2L by nasal cannula when ambulating" for R1.

During visits conducted during the investigation, LPA observed R1 in their apartment wearing their nasal cannula to their concentrator. LPA observed nasal cannula tube to be long enough to allow R1 to ambulate throughout their apartment. LPA observed R1's portable oxygen plugged in and charged during visits. LPA interviewed R1 during multiple visits, who stated that they are doing well and have no concerns regarding the facility. LPA interviewed staff members S1, S2, and S3, who stated that they ensure that R1 is wearing the nasal cannula to their oxygen while ambulating in the common areas of the facility and ensure that R1's portable oxygen is charged or plugged in and operating while in the common areas of the facility.

Based on interviews conducted, observations, and records reviewed, the preponderance of evidence standards have not been met. Therefore, the above allegations are found to be UNSUBSTANTIATED. A finding that a complaint allegation 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 was conducted with ED. A copy of this report was provided. Signature on these forms acknowledges receipt of these documents.
SUPERVISORS NAME: Anthony Perez
LICENSING EVALUATOR NAME: Michael Hood
LICENSING EVALUATOR SIGNATURE:

DATE: 01/03/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/03/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 2