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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 345002797
Report Date: 08/07/2025
Date Signed: 08/07/2025 04:52:02 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
04/29/2025 and conducted by Evaluator Michael Hood
COMPLAINT CONTROL NUMBER: 59-AS-20250429112340
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: 88DATE:
08/07/2025
UNANNOUNCEDTIME BEGAN:
12:25 PM
MET WITH:Pouya Ansari, Executive Director (ED)TIME COMPLETED:
02:30 PM
ALLEGATION(S):
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Facility is not addressing resident sustaining falls
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 investigation, the Department conducted interviews and reviewed documentation pertinent to the investigation.

The results of the investigation are as follows:

Allegation: Facility is not addressing resident sustaining falls

** Report continued on 9099-C **
Substantiated
Estimated Days of Completion:
NAME OF LICENSING PROGRAM MANAGER: Anthony Perez
NAME OF LICENSING PROGRAM ANALYST: Michael Hood
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 08/07/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/07/2025
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 8
Control Number 59-AS-20250429112340
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: 08/07/2025
NARRATIVE
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During visit conducted on May 6, 2025, LPA Angela Hood toured the facility, including resident (R1’s) apartment, and conducted an interview with R1. LPA observed R1’s walker was positioned next to bed with catheter bag hanging from walker to allow resident to get up and walk. LPA observed small rail at the head of R1’s bed to assist resident when getting up from bed. Interview with R1 indicated that they need a lot of help after breaking hip and are considered a fall risk due to vertigo. R1 indicated that they feel staff do not assist often and leave quickly to help other residents. LPA interviewed ED, who indicated that R1 had a fall and broke their hip on March 24, 2025. Additional interviews conducted by LPA Michael Hood did not indicate any concerns regarding how the facility addresses residents sustaining falls.

LPA Michael Hood reviewed records maintained on cite for R1, including R1’s Resident Assessments and Charting Notes. LPA observed, according to R1’s Charting Notes, that R1 was either observed or reported falls on October 11, 2024, November 11, 2024, January 5, 2025, March 24, 2025, May 23, 2025, and June 3, 2025. LPA received Unusual Incident/Injury Reports (SIRs) for falls dated November 11, 2024, January 5, 2025, March 24, 2025, and June 3, 2025. SIR for November 11, 2024 indicates that R1 was sent to the hospital after sustaining a fall and necessary reporting was conducted. SIR for January 5, 2024 indicates that R1 was sent to the hospital after sustaining a fall and necessary reporting was conducted. SIR for March 24, 2025 indicates that R1 was sent to the hospital after sustaining a fall and necessary reporting was conducted. SIR for June 3, 2025 indicates that R1 was sent to the hospital after sustaining a fall and necessary reporting was conducted.

LPA reviewed R1’s Resident Assessments dated April 15, 2025 and May 2, 2025. Neither assessment determined R1 as a fall risk. Charting Notes for R1 show that staff were monitoring R1 for falls starting April 25, 2025 upon R1’s return from the hospital. Charting Notes indicate that R1’s family was contacted on May 1, 2025 to add fall prevention to R1’s care plan and R1’s care plan was updated on May 20, 2025 to add fall prevention. LPA reviewed Resident Assessment for R1 dated May 20, 2025 and observed R1 to be determined as a fall risk.

** Report continued on 9099-C **
NAME OF LICENSING PROGRAM MANAGER: Anthony Perez
NAME OF LICENSING PROGRAM ANALYST: Michael Hood
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 08/07/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/07/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 8
Control Number 59-AS-20250429112340
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: 08/07/2025
NARRATIVE
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Charting Notes for October 11, 2024 states the following: “Resident paged at about 4am, told care staff [they] had a fall, however when Med Tech made more inquiries about how [they] fell, where, and if [they] hit [their] head, [R1] mentioned [they] hit [their] head on [their] bed, and [they] went on and on about how miserable [they were] feeling.” There is no other documentation for October 11, 2024 indicating what the facility did in response to R1 reporting a fall, whether they notified anyone, whether on cite nurse evaluated R1 for injuries, and whether emergency services were contacted. Facility could not provide any SIRs for R1 for the date of October 11, 2024 during investigation.

Charting Notes for May 23, 2025 states the following: “RESIDENT HAD AN UNWITNESSED FALL BY THE DOOR. [R1] WAS CALLING OUT FOR HELPED. [They were] ON THE FLOOR BEHIND THE DOOR. [Their] WALKER WAS BY [their] BED. WE HELPED [R1] UP AND [they] WALKED WITH THE WALKER TO [their] BED, A LITTLE BUMP ON HEAD. PUT ICE ON IT BUT [R1] SAID ITS TOO COLD TO TAKE IT AWAY. CALLED [family] FROM [their] PHONE AND INFORMED [them] ABOUT IT. [They] ASKED IF [R1] IS OK TOLD [them] YES. [They] SAID OK THANK YOU FOR CALLING AND LETTING [them] KNOW.” There is no other documentation for May 23, 2024 indicating whether on cite nurse evaluated R1 for injuries and whether emergency services were contacted. Facility could not provide any SIRs for R1 for the date of May 23, 2024 during investigation.

PIN 25-06-ASC states the following: “to ensure resident safety, licensees as a best practice should immediately call 9-1-1 if a resident is experiencing any of the following symptoms/conditions listed below: (…) Falls with suspected head injury.”

Based on records reviewed, the preponderance of evidence standards have been met. Therefore, the above allegation is found to be SUBSTANTIATED. Per California Code of Regulations, Title 22, Division 6, Chapter 8, a deficiency 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.
NAME OF LICENSING PROGRAM MANAGER: Anthony Perez
NAME OF LICENSING PROGRAM ANALYST: Michael Hood
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 08/07/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/07/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 8
Control Number 59-AS-20250429112340
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: 08/07/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Request Denied
Type A
08/08/2025
Section Cited
CCR
87465(g)
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87465 Incidental Medical and Dental Care (g) The licensee shall immediately telephone 9-1-1 if an injury or other circumstance has resulted in an imminent threat to a resident’s health including, but not limited to, an apparent life-threatening medical crisis except as specified in Sections 87469(c)(2), (c)(3), or (c)(4). This requirement is not met as evidenced by:
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Facility will conduct an in-service with staff regarding 9-1-1 reporting protocols. Facility will submit information regarding in-service training, including date of training and materials, to LPA by POC due date of 8/8/2025.
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Based on records reviewed, the facility did not ensure to contact 9-1-1 after R1 sustained falls with potential head injuries on two (2) occasions, which poses an immediate health, safety, and/or personal rights risk to the residents in care.
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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.
NAME OF LICENSING PROGRAM MANAGER: Anthony Perez
NAME OF LICENSING PROGRAM ANALYST: Michael Hood
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 08/07/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/07/2025
LIC9099 (FAS) - (06/04)
Page: 4 of 8
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
04/29/2025 and conducted by Evaluator Michael Hood
COMPLAINT CONTROL NUMBER: 59-AS-20250429112340

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: 88DATE:
08/07/2025
UNANNOUNCEDTIME BEGAN:
12:25 PM
MET WITH:Pouya Ansari, Executive Director (ED)TIME COMPLETED:
02:30 PM
ALLEGATION(S):
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Staff did not keep resident's room clean or sanitary

Facility staff are not providing adequate assistance with resident’s catheter

Facility staff are not providing adequate food services to residents in care

Facility staff are not providing proper hygiene assistance to residents in care
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 allegations listed above.

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

The results of the investigation are as follows:

Allegation: Staff did not keep resident's room clean or sanitary

Relevant party reported that facility staff were not keeping resident (R1’s) apartment clean and sanitary.

** Report continued on 9099-C **
Unsubstantiated
Estimated Days of Completion:
NAME OF LICENSING PROGRAM MANAGER: Anthony Perez
NAME OF LICENSING PROGRAM ANALYST: Michael Hood
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 08/07/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/07/2025
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 8
Control Number 59-AS-20250429112340
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: 08/07/2025
NARRATIVE
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During visit conducted on May 6, 2025, LPA Angela Hood toured the facility, including R1’s apartment, and conducted an interview with R1. LPA observed R1’s apartment to be clean and tidy. LPA did not observe any large stains on the floor or strong odors. Interview with R1 did not indicate any concerns with cleanliness of their apartment. R1 stated that they love living at the care home and would recommend the care home to anyone. LPA interviewed ED who stated that staff clean sheets, towels, and personal clothing once a week, as well as clean bathrooms and vacuum floors. ED stated that staff may clean apartment more often if resident soils themselves. ED stated that garbage is dumped more frequently (daily). ED stated that R1 eats in their room. ED stated that R1 has pulled out their catheter. ED stated that, a couple days after returning to the care home from the hospital, R1’s catheter had fallen out and leaked onto the floor. ED stated that carpet was cleaned with carpet extractor. ED stated that, after a second time R1’s catheter fell out, a work order was placed and completed to clean the carpet. LPA Michael Hood observed a work order to clean urine spill in R1’s apartment dated April 30, 2025.

Interview with residents R2, R4, and R5, as well as staff members S2, S3, S4, and S5 indicated that they have never observed anywhere in the facility to be unclean or in disrepair. S2, S3, and S4 stated that housekeeping and maintenance do a good job at the facility. Interview with representative from Home Health agency assisting R1 with their catheter indicated that the nurses assisting R1 had no concerns regarding cleanliness of the facility.

During visit conducted on May 21, 2025, LPA observed R1 and their apartment and observed R1’s apartment to be clean and sanitary. During visits conducted on May 20, 2025, May 21, 2025, July 30, 2025, August 6, 2025, and August 7, 2025 LPA Michael Hood observed areas toured at the care home to be clean and in good repair.

Allegation: Facility staff are not providing adequate assistance with resident’s catheter

Relevant party reported that facility staff were not providing adequate assistance with R1’s catheter.

** Report continued on 9099-C **
NAME OF LICENSING PROGRAM MANAGER: Anthony Perez
NAME OF LICENSING PROGRAM ANALYST: Michael Hood
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 08/07/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/07/2025
LIC9099 (FAS) - (06/04)
Page: 6 of 8
Control Number 59-AS-20250429112340
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: 08/07/2025
NARRATIVE
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During visit conducted on May 6, 2025, LPA Angela Hood toured the facility, including R1’s apartment, and conducted an interview with R1. LPA observed R1’s catheter bag to be new and empty. LPA observed R1’s walker was positioned next to bed with catheter bag hanging from walker to allow resident to get up and walk. Interview with R1 indicated that they feel uncomfortable having a catheter. Interview with ED indicated that R1 returned to the facility after being hospitalized and had pulled their catheter out the first night back. ED stated that R1 had pulled out their catheter twice. ED stated that R1’s Home Health agency was caring for R1’s catheter, while facility staff monitored the situation prior to R1’s Home Health being established. ED stated that R1 was sent to the hospital on April 26, 2025 regarding R1 removing their catheter. Unusual Incident/Injury Report (SIR) dated April 26, 2025 regarding the incident indicated that R1 had no complaints of pain and R1 returned to the community with urinary catheter replaced. ED stated that facility caregivers were responsible for changing out the catheter bag while Home Health provided extra bags. ED stated that facility caregivers were responsible for cleaning the catheter insertion point.

Interviews with S2, S3, and S4 indicated that they didn’t have any concerns regarding facility staff’s assistance with residents’ catheters.

Interview with representative from Home Health agency assisting R1 with their catheter indicated that the nurses providing assistance to R1 regarding their catheter did not have any issues with the environment of the facility or neglect. Home Health records indicate that R1 started Home Health services on April 28, 2025.
Allegation: Facility staff are not providing adequate food services to residents in care

During visit conducted on May 6, 2025, LPA Angela Hood met with R1 and conducted an interview with R1. R1 indicated that food at the facility is “excellent” and they have no complaints about the food at the facility. R1 stated that they get plenty of food to eat. Interview with ED indicated that R1 eats specific things that the facility provides.

Interview with R2, R4, and R5, as well as S2, S3, S4, and S5 indicated that they did not have any concerns regarding food services at the facility. R2, R3, R5, and staff member (S1) acknowledged that there is a "chef forum" in which residents can disclose their food preferences to the facility chef.
** Report continued on 9099-C **
NAME OF LICENSING PROGRAM MANAGER: Anthony Perez
NAME OF LICENSING PROGRAM ANALYST: Michael Hood
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 08/07/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/07/2025
LIC9099 (FAS) - (06/04)
Page: 7 of 8
Control Number 59-AS-20250429112340
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: 08/07/2025
NARRATIVE
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LPA Michael Hood toured the kitchen on May 20, 2025 and August 6, 2025 and observed food at the facility to be of good quality.

Allegation: Facility staff are not providing proper hygiene assistance to residents in care

During visit conducted on May 6, 2025, LPA Angela Hood toured the facility, including R1’s apartment, and conducted an interview with R1. LPA observed R1 to be clean and their hygiene needs to be met. LPA did not observe any large stains on the floor or strong odors. R1 stated that there was one caregiver providing showers where the water was cold and the caregiver was a little rough handling R1, but they haven’t had a shower with the caregiver since their negative experience. R1 stated that facility staff are like family and are very kind. Interview with ED indicated that staff clean sheets, towels, and personal clothing once a week, as well as clean bathrooms and vacuum floors. ED stated that staff may clean apartment more often if resident soils themselves. ED stated that R1 requires assistance with showering.

Interview with R2, R3, R4, and R5 indicated that they are treated well by facility staff and they feel that their care needs are being met at the facility. Interview with S2, S3, S4, and S5 indicated that they have no concerns regarding hygiene assistance provided to the residents in need at the care home. Interview with representative from Home Health agency assisting R1 with their catheter indicated that nurses assisting R1 did not have any concerns regarding hygiene assistance or incontinence care for R1. LPA Michael Hood reviewed records maintained on cite for R1, including R1’s Staff Assignments by Month by Unit, which indicated that R1 was receiving daily assistance with activities of daily living.

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. A copy of this report was provided. Signature on these forms acknowledges receipt of these documents.
NAME OF LICENSING PROGRAM MANAGER: Anthony Perez
NAME OF LICENSING PROGRAM ANALYST: Michael Hood
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 08/07/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/07/2025
LIC9099 (FAS) - (06/04)
Page: 8 of 8