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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 345002797
Report Date: 05/22/2025
Date Signed: 05/22/2025 04:05:43 PM

Substantiated


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
03/28/2025 and conducted by Evaluator Michael Hood
COMPLAINT CONTROL NUMBER: 59-AS-20250328120733
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: 82DATE:
05/22/2025
UNANNOUNCEDTIME BEGAN:
12:35 PM
MET WITH:Pouya Ansari, Executive DirectorTIME COMPLETED:
04:20 PM
ALLEGATION(S):
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Licensee is not ensuring that staff are adequately trained on emergency evacuation protocols.
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 for the complaint allegation listed above.

During the investigation, LPA conducted interviews and reviewed documentation pertinent to the investigation. The results of the investigation are as follows:

Allegation: Licensee is not ensuring that staff are adequately trained on emergency evacuation protocols.

Relevant party reported to the Department that the facility had a fire on February 1, 2025 and staff were not properly trained on emergency evacuation protocols to properly address resident evacuations during fire.

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

DATE: 05/22/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/22/2025
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 4
Control Number 59-AS-20250328120733
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: 05/22/2025
NARRATIVE
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Interview with ED indicated that there was a small fire in the laundry room in the Memory Care Unit (MCU) on February 1, 2025 caused by a dryer in the laundry room. ED stated that staff were supposed to only evacuate residents in the MCU during fire on February 1, 2025, while some residents with oxygen were to shelter in place with care staff supervision. ED stated that fire department was contacted via the alarms and arrived promptly to address the fire. ED stated that the fire was put out when the sprinkler system was activated. LPA received an incident report from Sacramento Metropolitan Fire indicating that a fire took place on the premises February 1, 2025. Fire alarm activated at 5:56 AM and fire fighters arrived at the facility at 6:02 AM. Last unit was cleared at 7:29 AM. Incident type was "fires in structure other than building." Incident resulted in zero (0) injuries or deaths. Fire fighters reported light smoke condition in the hallway with occupants evacuating. Officer reported assisting with occupant evacuation on the second floor. Fire was contained to the laundry room in the clothes dryer and smoke was being exhausted to the exterior. Rooms 106-122 were uninhabitable due to smoke and/or water/smoke impacts. Engineer shut off and drained sprinkler system. Officer replaced the open sprinkler head and recharged the sprinkler system. Report indicated the origin of the fire to be the laundry room contained to a commercial clothes dryer due to a large lint trap.

Interviews with staff members S1, S2, and S3 indicated that they do not feel adequately trained on emergency evacuation protocols. S1 stated that they were at the facility on February 1, 2025 during the fire and didn't feel properly trained on how to address a fire at the facility. S1 stated that they were not properly trained on getting wheelchair bound residents evacuated. S1 stated that the fire department was contacted when the fire alarms went off. S1 stated that they were already evacuating residents due to the smoke and got everyone out in 20 minutes at the most. S1 stated that more than half of the residents were evacuated when the fire department arrived. S1 stated that half the top floor was not evacuated, including room 237, and room 225 to room 231. S1 stated that no one had told staff not to evacuate the second floor. S1 stated that a few residents downstairs were not evacuated, including bed bound residents who needed hoyer lift assistance. S2 stated that they were at the facility during fire on February 1, 2025. S2 stated that they have worked at the facility for two (2) and a half years and has only participated in one quarterly drill. S2 stated that they were evacuating residents on the second floor and only 85 to 90 percent of the second floor was evacuated. S2 stated that they didn't feel prepared to handle the emergency. S3 indicated that they have never received Disaster and Emergency Plan training and have not participated in a quarterly drill.
** Report continued on 9099-C **
SUPERVISORS NAME: Anthony Perez
LICENSING EVALUATOR NAME: Michael Hood
LICENSING EVALUATOR SIGNATURE:

DATE: 05/22/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/22/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 4
Control Number 59-AS-20250328120733
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: 05/22/2025
NARRATIVE
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LPA reviewed facility's Plan of Operation maintained at Sacramento North Regional Office. LPA observed Operations Policy revised January 1, 2019 indicated the following: "Disaster and Emergency Plan...All staff will receive training on the Disaster and Emergency Plan upon hire and annually thereafter. The training will include staff responsibilities during an emergency or disaster." No objectives and content for Disaster and Emergency Plan training was indicated in Operations Policy.

LPA observed training documentation for staff members S3, S4, S5, and S6. LPA observed that staff received "Fire Safety" training via Relias Learning upon hire and annually. LPA observed the course objectives for the Fire Safety training in Relias Learning, but could not verify if Fire Safety training met the requirements indicated in the Plan of Operation for Disaster and Emergency Plan training. LPA observed documentation for an annual review of the facility's Emergency and Disaster Plan conducted for the years of 2021, 2022, 2023, and 2024. LPA observed that documentation indicated that the Executive Director conducted the review of the plan with existing employees for the years of 2021 and 2022. Documentation did not include a list of the employees who participated in the review and was not documented in accordance with Title 22 regulations regarding personnel training. LPA observed that the documentation for the annual review of the Emergency and Disaster for 2023 and 2024 did not indicate that the plan was reviewed with existing employees.

Based on interviews conducted and records reviewed, the preponderance of evidence standards have been met. Therefore, the above allegations are found to be SUBSTANTIATED. Per California Code of Regulations, Title 22, Division 6, Chapter 8, deficiencies are being cited on the attached 9099-D page.

Exit interview was conducted with ED. A copy of this report and appeal rights were provided. Signature on these forms acknowledges receipt of these documents.
SUPERVISORS NAME: Anthony Perez
LICENSING EVALUATOR NAME: Michael Hood
LICENSING EVALUATOR SIGNATURE:

DATE: 05/22/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/22/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 4
Control Number 59-AS-20250328120733
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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/22/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
06/27/2025
Section Cited
CCR
87208(a)
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87208 Plan of Operation (a) The licensee shall have and maintain a current, written definitive plan of operation for the facility. The licensee shall operate the facility in accordance with the terms specified in the plan of operation and may be cited for not doing so pursuant to Health and Safety Code section 1569.49. (...) This requirement is not met as evidenced by:
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Facility will create a plan to address Emergency and Disaster Plan training which includes specifying objectives of training in Plan of Operation, documenting training in accordance with Title 22 personnel training, and ensuring all staff are actively participating in training.
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Based on interviews conducted and records reviewed, the facility did not ensure that there was adequate records ensuring staff were trained in Emergency and Disaster Plan in accordance with the facility's Plan of Operation, which poses a potential health, safety, and personal rights risk to the residents in care.
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Plan will be submitted to LPA by POC due date.
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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: Anthony Perez
LICENSING EVALUATOR NAME: Michael Hood
LICENSING EVALUATOR SIGNATURE:

DATE: 05/22/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/22/2025
LIC9099 (FAS) - (06/04)
Page: 4 of 4