345002797-9-30-2025-59-AS-LCRR-DMFVM9-20251014163311

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 345002797
Report Date: 09/30/2025
Date Signed: 09/30/2025 11:09:27 AM

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
05/28/2025 and conducted by Evaluator Michael Hood

COMPLAINT CONTROL NUMBER: 59-AS-20250528102331

FACILITY NAME:	OAKMONT OF FAIR OAKS		FACILITY NUMBER:	345002797
ADMINISTRATOR:	POUYA ANSARI		FACILITY TYPE:	740
ADDRESS:	8484 MADISON AVE.		TELEPHONE:	(916) 633-1001
CITY:	FAIR OAKS	STATE: CA	ZIP CODE:	95628
CAPACITY:	128	CENSUS: 92	DATE:	09/30/2025
		UNANNOUNCED	TIME BEGAN:	10:00 AM
MET WITH:	Pouya Ansari, Executive Director (ED)		TIME COMPLETED:	11:25 AM

ALLEGATION(S):

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Staff did not seek medical attention for resident in a timely manner.

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

The results of the investigation are as follows:

Allegation: Staff did not seek medical attention for resident in a timely manner.

** Report continued on 9099-C **

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Anthony Perez
LICENSING EVALUATOR NAME: Michael Hood
LICENSING EVALUATOR SIGNATURE:	DATE: 09/30/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/30/2025

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 59-AS-20250528102331

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: 09/30/2025

NARRATIVE

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Relevant party reported that something had happened to resident (R1) prior to May 25, 2025, when R1 was hospitalized and facility staff did not report changes to R1's authorized representative. LPA conducted interviews with seven (7) staff members, including the Memory Care Director (MCD), who all claimed they noticed a decline in R1 a month or two (2) prior to R1's May 25, 2025 hospitalization. R1 was reported to be moving slower, not eating as much, and not participating in their usual activities. R1's decline was reported to be slow and gradual. Interviews with staff attributed these changes to R1’s dementia diagnosis. Observations made by staff were reported to the Med-Techs and the MCD. MCD claimed that R1 was not sick until the day R1 was sent out to the hospital. MCD stated that, at that time, “everyone” was having a cold in the Memory Care Unit (MCU). R1 had two (2) “accidents” of incontinence which is “out of the ordinary” for R1. MCD confirmed that they were made aware by staff of the changes noticed in R1 and that family and doctor were aware of the changes in resident’s eating habits.

On May 25, 2025, R1 was admitted for (but not limited to) the following:
o Acute metabolic encephalopathy (brain dysfunction caused by an underlying condition. The underlying condition can cause a chemical imbalance in the blood. As a result, the brain doesn’t get what it needs to function as expected. Metabolic encephalopathies usually develop acutely or sub acutely and are reversible if the systemic disorder is treated. If left untreated, however, metabolic encephalopathies may result in secondary structural damage to the brain.)
o Severe sepsis (a serious condition in which the body responds improperly to an infection. The infection-fighting processes turn on the body, causing the organs to work poorly. Sepsis may progress to septic shock – a dramatic drop in blood pressure that can damage the lungs, kidneys, liver and other organs. When the damage is severe, it can lead to death) secondary to community-acquired pneumonia
o Mass in the left mid lung (previously noted on R1's previous hospitalization on March 5, 2024).

R1 completed a five (5) day course of antibiotics for pneumonia. After discussions of need for lung mass biopsy and risks of potential chemotherapy, R1's family decided to not pursue biopsy. During R1's admission, R1 was noted to be an aspiration risk, and R1 was made NPO (nothing by mouth). Repeat evaluation allowed upgrade to a dysphagia diet, but R1 remained with poor oral intake due to lack of appetite. Family was not interested in artificial nutrition or feeding tube. After palliative and hospice team discussions, family decided on hospice. R1 was discharged on hospice on May 30, 2025.
** Report continued on 9099-C **

SUPERVISORS NAME: Anthony Perez
LICENSING EVALUATOR NAME: Michael Hood
LICENSING EVALUATOR SIGNATURE:	DATE: 09/30/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/30/2025

LIC9099 (FAS) - (06/04)

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Control Number 59-AS-20250528102331

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: 09/30/2025

NARRATIVE

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Relevant party also reported concerns regarding potential neglect resulting in an incident on March 5, 2024. Per incident report received by the Department, R1 was experiencing cough and was advised to be sent out to ER via ambulance. R1's authorized representative was notified. R1 was admitted and went back to the facility on March 8, 2024 with oral antibiotics. A follow up visit by R1's primary care physician was conducted on March 11, 2024. Medical records for March 5, 2024 incident indicate that R1 presented with shortness of breath and hypotension concerning for underlying pneumonia versus urinary tract infection meeting criteria for sepsis. A 10 mm nodule midlung is nonspecific and not seen on previous exams. R1 was treated with antibiotics and fluids and discharged back to facility on March 8, 2024.

R1 was noted with cognitive and physical changes one (1) to two (2) months prior to their hospitalization on May 25, 2025. All staff interviewed noted the changes to be slow and gradual. As claimed by MCD, family and doctor were made aware. R1 was sent out by facility when resident was experiencing acute changes, and R1's family was also notified. Based on the medical records in the hospital, resident was admitted for (but not limited to) acute metabolic encephalopathy, severe sepsis secondary to community-acquired pneumonia, and mass of upper lobe of left lung. There is no evidence that R1 was neglected by facility for this incident. As for the incident on March 5, 2024, there is no specific evidence that R1 was neglected by facility.

LPA conducted an interview with R1's authorized representative, who confirmed that facility reported changes in R1's condition. LPA conducted interviews with residents R1, R2, R3, R4, R5, and R6 during investigation. R2, R3, R4, R5, and R6 stated that they are treated well by facility staff and that their care needs are being met. R2, R3, R4, R5, and R6 stated that they have not witnessed any residents in need of care and not receiving assistance from facility care staff.

Based on interviews conducted and records reviewed, the preponderance of evidence standards have not been met. Therefore, the above allegation is 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.

SUPERVISORS NAME: Anthony Perez
LICENSING EVALUATOR NAME: Michael Hood
LICENSING EVALUATOR SIGNATURE:	DATE: 09/30/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/30/2025

LIC9099 (FAS) - (06/04)

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