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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 345002797
Report Date: 04/02/2026
Date Signed: 04/02/2026 06:55:02 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
01/05/2026 and conducted by Evaluator Sabrina Calzada
PUBLIC
COMPLAINT CONTROL NUMBER: 59-AS-20260105150814
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: 84DATE:
04/02/2026
UNANNOUNCEDTIME BEGAN:
12:50 PM
MET WITH:Pouya Ansari, Administrator TIME COMPLETED:
01:40 PM
ALLEGATION(S):
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Facility has insufficient staff to meet the care needs of the residents.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Sabrina Calzada arrived unannounced to continue the investigation and met with Administrator, Pouya Ansari and Business Office Director, Habi Torres. LPA stated the reason for today's inspection.

During the investigation, the Department interviewed the Administrator, the Health and Services Director/Licensed Vocational Nurse (LVN), multiple facility staff and (2) famil members of resident (R1). The Department reviewed documentation, including (R1's) Physician's Report, care plans, Medication Administration Records (MAR), charting notes and incident report (LIC624). The results of the investigation are as follows:

Resident (R1) moved to the community in June 2022 and transferred to the Memory Care Unit (MCU) in 2024. The Physician's Report (10/15/2024) notes a diagnosis of: a fall, Left Femoral Neck Fracture, Dementia, incontinent with bladder, confused/disoriented, unable to transfer independently.
*cont on 9099C-1..
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Lauren Crocker
LICENSING EVALUATOR NAME: Sabrina Calzada
LICENSING EVALUATOR SIGNATURE:

DATE: 04/02/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/02/2026
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 6
Control Number 59-AS-20260105150814
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: 04/02/2026
NARRATIVE
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90099C-1.. Allegation: Facility has insufficient staff to meet the care needs of the residents. The allegation states the facility did not provide sufficient staffing which resulted in (R1) falling, breaking their hip and requiring a wheelchair.

The Administrator confirmed that (R1) did not have a fall in January 2026, when the complaint was filed, but had a fall in October 2024 which resulted in a change in condition. The Administrator confirmed (R1) still uses a wheelchair, has been on fall management following the fall on October 9, 2024, and (R1) was sent to the Emergency Room after this fall due to complaining of pain. The incident report completed and submitted to the Department on October 11, 2024, notes (R1) was sent to the Emergency Room (ER) due to (R1) complaining of “lower extremity pain with movement”.

The charting notes state that on October 9, 2024 (8:04 pm), (R1) had an unwitnessed fall in the common area/dining room and that the family member was contacted and requested to be notified if (R1) needs to go the ER. The subsequent entry indicates that (R1) was sent out to the Emergency Room on October 10, 2024 (8:14 pm) per the family member’s request due to resident stating they were in pain and not being able to move their left side. (R1) returned from the hospital on October 15, 2024 (6:00 pm).

The LVN stated she was not at the community when (R1) fell on October 9, 2024, as it occurred around 8:00 pm after her shift ended. Two Med-Tech staff who work “am” shift stated they didn’t recall the fall (R1) had on October 9, 2024 (8:00 pm) but recalled (R1) being at the hospital and then returning in a wheelchair. These staff indicated (R1) has had no other serious falls or any pressure wounds. A family member stated that "(R1) wasn't using a walker as a habit" which contributed to the fall, and "staff were instrumental in getting (R1) to recover better". This family member commented that she observed there to be sufficient staffing each day of the week when visiting (R1).

Staffing schedules reflected (4) care staff and (1) Med-Tech scheduled on am/pm shifts and (3) care staff scheduled on NOC shift for approximately (32) residents residing in MCU.

The care plan in place at the time of the fall indicated that Resident is at risk for falling and requires staff observation to promote safety, but does not require use of an assistive device. The care plan was updated on 11/14/2024 and reflected an increase in care (R1)requires total assistance with dressing, feeding, toileting, transferring, escorting (wheelchair). Remains on Fall Management.

Based on information obtained, the department finds the allegation 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.

SUPERVISORS NAME: Lauren Crocker
LICENSING EVALUATOR NAME: Sabrina Calzada
LICENSING EVALUATOR SIGNATURE:

DATE: 04/02/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/02/2026
LIC9099 (FAS) - (06/04)
Page: 2 of 6
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
01/05/2026 and conducted by Evaluator Sabrina Calzada
PUBLIC
COMPLAINT CONTROL NUMBER: 59-AS-20260105150814

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: DATE:
04/02/2026
UNANNOUNCEDTIME BEGAN:
12:50 PM
MET WITH:Pouya Ansari, Administrator TIME COMPLETED:
01:40 PM
ALLEGATION(S):
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Facility staff are mismanaging resident's medications.
Facility is not ensuring adequate food services for the residents in care.
False claims.
INVESTIGATION FINDINGS:
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During the investigation, the Department interviewed the Administrator, the Health and Services Director/Licensed Vocational Nurse (LVN), multiple facility staff and (2) famil members of resident (R1). The Department reviewed documentation, including (R1's) Physician's Report, care plans, Medication Administration Records (MAR), charting notes and incident report (LIC624).

The results of the investigation are as follows:

*cont on 9099A-C-1..
Unfounded
Estimated Days of Completion:
SUPERVISORS NAME: Lauren Crocker
LICENSING EVALUATOR NAME: Sabrina Calzada
LICENSING EVALUATOR SIGNATURE:

DATE: 04/02/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/02/2026
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 3 of 6
Control Number 59-AS-20260105150814
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: 04/02/2026
NARRATIVE
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9099A-C-1- Allegation: Facility staff are mismanaging resident's medications. The allegation states that (R1) has erratic medication delivery and is not administered medications regularly as ordered.

LPA asked the Licensed Vocational Nurse (LVN) about medications arriving at different times and possibly being missed. The LVN stated (R1) was on hospice previously, graduated in 2025, and their medications from their health care provider are repackaged in bubble packs. The LVN stated she does medication audits weekly, and there have been no errors with (R1’s) medications.

A Med-Tech stated she administers medications to (R1), there are "no issues", and there is a crush order in place. Thie Med-Tech confirmed (R1’s) medications are ordered through an in-house pharmacy and (R1’s) family member also brings in some medication bottles from (R1’s) health care provider, and the facility will send the medications to the in-house pharmacy so they can package them in bubble packs. This Med-Tech indicated medication refills with the health care provider are usually 90 days, and they are 30-60 days with the in-house pharmacy, so they always have extra on hand, and (R1) never runs out.

A second staff who works as a Med-Tech indicated that there is a crush order on file and there are no issues with (R1) taking medications

A family member of (R1) who visits multiple times each week indicated that there are no missed medications or late refills and commented that she "brings extra medications" to the facility. This family member explained that the refill process has changed recently- sometimes she orders medications through the primary health provider, and the in-house pharmacy can do so also.

LPA reviewed copies of the MAR from Jan- Mar 2026 for (R1). All months showed (4) scheduled medications were administered as ordered; and (1) PRN administered- Trazadone 25 mg, was administered several times and documented as required, including if the medication was effective.

Based on information obtained, allegation is found to be UNFOUNDED- A finding that the allegation is unfounded means that the allegation is false, could not have happened, and/or is without a reasonable basis.

*cont n 90909A-C2..

SUPERVISORS NAME: Lauren Crocker
LICENSING EVALUATOR NAME: Sabrina Calzada
LICENSING EVALUATOR SIGNATURE:

DATE: 04/02/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/02/2026
LIC9099 (FAS) - (06/04)
Page: 4 of 6
Control Number 59-AS-20260105150814
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: 04/02/2026
NARRATIVE
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9099A-C-2.. Allegation: Facility is not ensuring adequate food services for the residents in care. The allegation states the food served in the Memory Care Unit (MCU) is unsatisfactory in amount and quality compared to what is served on the assisted living unit (ALU). Additionally, (R1) may not be receiving what is necessary to keep her healthy.

A family member stated she believes there are enough options, there are always sandwiches available at every meal, and the portions are usually fine. Additionally, this family member stated staff were “instrumental in getting (R1) to recover better” and (R1) enjoys the Boost shakes staff provide with medications.

Multiple staff stated that MCUt has the same menu as ALU, but the food is not presented the same. In MCU, the food is not plated ahead of time but right before it's served. Additionally, staff indicated that water is served with all meals, water pitchers are delivered with the food on the carts from the main kitchen, staff will consider resident's dietary restrictions, and residents can order sandwiches too as an alternative to the daily special. A Med-Tech staff stated (R1) "doesn't need pureed food and can eat solids, salads, fries and likes sweets", and all staff indicated that (R1) requires assistance with feeding, but eats well. This staff indicated she doesn't see a difference in the serving size in MCU than what is served in ALU, but ALU is more like a restaurant with more menu choices.

Staff confirmed fruit is always served with breakfast, salads for lunch and staff make smoothies to offer residents for snack time. LPA observed Smoothies to be the morning snack item on 3/25/26.

The LVN stated (R1) "started improving a lot because they ate and drank better and had feeding assistance and confirmed residents are given fruit smoothies every afternoon. The LVN explained that the ALU kitchen makes the same food for MCU, and staff know each resident individually so they know how much to serve them, commenting that the resident can always have second portions, and there are (3) snacks served daily.

Care Plan dated 11/14/2024- reflects increased care needs, including requiring total assistance with feeding

The chef stated that there is a menu the facility follows daily, and it is the same for ALU and MCU and explained the daily special is changed as well as the weekly special. The chef explained that residents in ALU "pre-order" their food as they are able to read and order from the menu and stated the main kitchen will send food in a hot box to MCU. The Chef confirmed that all food is ordered from the same vendor, and 95% of the food is made from scratch", and commented, "most people eat whatever the special is and we plate everything the same". *cont on 9099A-C-3..

SUPERVISORS NAME: Lauren Crocker
LICENSING EVALUATOR NAME: Sabrina Calzada
LICENSING EVALUATOR SIGNATURE:

DATE: 04/02/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/02/2026
LIC9099 (FAS) - (06/04)
Page: 6 of 6
Control Number 59-AS-20260105150814
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: 04/02/2026
NARRATIVE
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9099A-C-3..The Chef was asked about the quantity of food served in MCU and ALU and replied "Yes, memory care residents don't eat as much- the food served in ALU is presented a little differently”. Additionally, staff do take orders in MCU and will ask residents what they want, complete an order paper, and check if there are any variations such as vegetarian or if proteins need to be cut in a smaller size, commenting, “the kitchen knows what it is preparing".

On March 25, 2026, LPA observed (R1) to be sitting/sleeping in her wheelchair at the end of the bar/counter and resting after just finishing lunch. The staff who assisted (R1) with feeding on March 25, 2026, indicated that (R1) had a quesadilla, some French fries and a bowl and a half of soup for lunch today.

LPA confirmed the daily lunch special on April 2, 2026- in ALU and MCU was Ultimate Veggie Pizza. There are two dinner specials today, in ALU and MCU- Tilapia with rice and Indian vegetable Samosas. The breakfast special today was Chef's Omelette

Based on information obtained, the allegation is determined to be A finding that the allegation is unfounded means that the allegation is false, could not have happened, and/or is without a reasonable basis.

Allegation: False claims. The allegation states that the facility advertises it has a nurse, but a nurse has never been seen when visiting the facility.

The facility Administrator confirmed the facility has a nurse, who is the Health and Services Director, and she is on site 5 days/week, and on-call- Sundays through Thursdays.



LPA interviewed the Licensed Vocational Nurse (LVN) who works at the facility. The LVN stated she works at the facility from Sunday through Thursday, and sometimes on Saturdays, and confirmed she is the only nurse currently working at the facility. The LVN stated she has interacted with both of (R1’s) family members who regularly visit (R1) during the 1.5 years she has worked at this location. A family member indicated that she always sees this LVN at the facility when she visits weekly.

Based on information obtained, the allegation is determined to be A finding that the allegation is unfounded means that the allegation is false, could not have happened, and/or is without a reasonable basis. Exit interview. Copy of report emailed.
SUPERVISORS NAME: Lauren Crocker
LICENSING EVALUATOR NAME: Sabrina Calzada
LICENSING EVALUATOR SIGNATURE:

DATE: 04/02/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/02/2026
LIC9099 (FAS) - (06/04)
Page: 5 of 6