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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 347005115
Report Date: 09/25/2024
Date Signed: 09/25/2024 02:46:54 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
06/05/2024 and conducted by Evaluator Michael Hood
COMPLAINT CONTROL NUMBER: 59-AS-20240605165036
FACILITY NAME:FAIR OAKS HOME CARE FOR THE ELDERLYFACILITY NUMBER:
347005115
ADMINISTRATOR:LYUDMILA PALAMARCHUKFACILITY TYPE:
740
ADDRESS:8119 OAHU DRIVETELEPHONE:
(916) 962-7458
CITY:FAIR OAKSSTATE: CAZIP CODE:
95628
CAPACITY:6CENSUS: 6DATE:
09/25/2024
UNANNOUNCEDTIME BEGAN:
01:05 PM
MET WITH:Lyudmila Palamarchuk, AdministratorTIME COMPLETED:
03:00 PM
ALLEGATION(S):
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Questionable Death
INVESTIGATION FINDINGS:
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Licensing Program Analysts (LPAs) Michael Hood and Cassie Mikkelson arrived at the facility and met with Administrator, Lyudmila Palamarchuk, to deliver findings into the allegation listed above.

During the investigation, the Department obtained and reviewed records pertinent to the investigation.

A review of resident (R1's) Admission Agreement shows that R1 was admitted to the facility on 9/22/2022. A review of R1's Physician's Report LIC 602A indicates that R1 was diagnosed with Alzheimers Dementia with behavioral disturbance on 4/2018. A review of R1's death certificate indicated no signs of suspicion regarding death. Cause of death for R1 listed on their death certificate is Alzheimer's/Dementia with Behavioral Disturbance. There were not significant conditions or indicators that contributed to R1's death.

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

DATE: 09/25/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/25/2024
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-20240605165036
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: FAIR OAKS HOME CARE FOR THE ELDERLY
FACILITY NUMBER: 347005115
VISIT DATE: 09/25/2024
NARRATIVE
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 R1's date of death was listed as 11/14/2022 at approximately 1708 hours. The manner of R1's death was natural and not referred to Sacramento County Coroner's Office.

Based on observations 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 with Administrator. 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: 09/25/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/25/2024
LIC9099 (FAS) - (06/04)
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