345002797-9-22-2026-59-AS-LCRR-DYEW5R-20260930165934

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 345002797
Report Date: 09/22/2026
Date Signed: 09/22/2026 02:15:44 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
07/17/2026 and conducted by Evaluator Sabrina Calzada

PUBLIC

COMPLAINT CONTROL NUMBER: 59-AS-20260717121658

FACILITY NAME:	OAKMONT OF FAIR OAKS		FACILITY NUMBER:	345002797
ADMINISTRATOR:	ANYSSA D HILL		FACILITY TYPE:	740
ADDRESS:	8484 MADISON AVE.		TELEPHONE:	(916) 633-1001
CITY:	FAIR OAKS	STATE: CA	ZIP CODE:	95628
CAPACITY:	128	CENSUS: 84	DATE:	09/22/2026
		UNANNOUNCED	TIME BEGAN:	01:15 PM
MET WITH:	Anyssa Hill, Administrator		TIME COMPLETED:	01:40 PM

ALLEGATION(S):

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Facility is not addressing resident sustaining falls.
Facility is not providing adequate food services to residents in care.
Facility is not sending emails to resident's family member as requested.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Sabrina Calzada arrived unannounced to deliver findings to a complaint received on July 17, 2026 and met with Anyssa Hill, Administrator. LPA stated the reason for today's inspection.

During the investigation, LPA interviewed the current Administrator, the Health and Services Director, Activities Director, (4) Memory Care staff and (2) family members of (R1). LPA was unable to interview (R1) due to their diagnosis but observed (R1) resting in their bed on July 23, 2026 and on September 9, 2026. LPA reviewed pertinent documents including, the Physician's Report (dated October 15, 2024) , current care plan (dated May 29, 2026), various email communications, a Pre-Hospital Care Report (dated June 24, 2026), charting notes and hospice notes.

The results of the investigation are as follows:

*report continued on 9099C-1..

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Lauren Crocker
LICENSING EVALUATOR NAME: Sabrina Calzada
LICENSING EVALUATOR SIGNATURE:	DATE: 09/22/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/22/2026

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 5

Control Number 59-AS-20260717121658

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: 09/22/2026

NARRATIVE

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9099C-1. Resident (R1) moved to the community on/around June 2022. The Physician's Report notes (R1) has a primary diagnosis of a "Fall with left Femoral Neck Fracture". Additional diagnosis include Hyperlipidemia and Dementia. (R1) is noted to be Incontinent with bladder, confused/disoriented and requires assistance with all Activities of Daily Living (ADL's). The Physician's Report notes that (R1) is Non-ambulatory and unable to transfer independently to/from bed. LPA reviewed documentation on file that the individual who holds Power of Attorney (POA) for (R1) refused an annual doctor’s visit on February 21, 2026.

Allegation: Facility is not addressing resident sustaining falls. The allegation states (R1) recently had a second very serious fall that caused a stressful hospitalization for (R1), long recovery periods where (R1) is literally bedridden in their room, and lowered the quality of their life in these last days.

The Health and Services Director (HSD) confirmed (R1) fell on June 22, 2026 (6:49 pm) and (R1's) POA/responsible person, initiated the x-ray (mobile). The charting notes say the mobile x-ray was completed on June 23, 2026. The HSD stated on September 9, 2026 that the Activities Director "takes the time to feed (R1) breakfast and lunch " when she is here and (R1) is "on hospice, stable and doing very well" and "" is healing well" from the fall and wound.

One staff who has worked in the Memory Care Unit (MCU) for 3 years stated, "(R1)s first fall changed everything- their speech slowed down as well as their cognition- it is more difficult now to communicate with (R1)".

This staff was asked about (R1's) second fall, on June 22, 2026 and stated "(R1) had the 1/2 rails up on the bed and the fall mat in place" and "saw the fall sensor footage and (R1) didn't really fall- they scooted away from the rails that were on the top half of their bed- and slid very smoothly to the mat", which is somewhat thick. The staff clarified that when (R1) "slid off the bed, their legs were in a bent position, so they fell on their knees".

The staff stated that "(R1) complained about pain on the opposite side of where they fell, which is not uncommon for residents, yet (R1) appeared okay with no noticeable injuries. This staff they assessed (R1) and did not see any signs/symptoms of an injury, and (R1's) family member who holds Power of Attorney for medical "did not want to send (R1) out on June 22, 2026, and wanted to see how she does".
*cont on 9099C-2..

SUPERVISORS NAME: Lauren Crocker
LICENSING EVALUATOR NAME: Sabrina Calzada
LICENSING EVALUATOR SIGNATURE:	DATE: 09/22/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/22/2026

LIC9099 (FAS) - (06/04)

Page: 3 of 5

Control Number 59-AS-20260717121658

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: 09/22/2026

NARRATIVE

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9099C-2.. This staff explained that they looked at the footage video, which is an internal video, following the fall and also asked another Med-Tech who worked in Assisted Living Unit to view the video, and the second staff didn't think the fall looked that serious. The staff in MCU stated the next day, approximately 24 hours later, (R1) complained of pain and indicated that (R1) could push the call button at that time. The MCU staff expressed how the "new fall sensors are super helpful" to staff in seeing what occurred prior to and following the fall, up to (10) minutes total.

LPA interviewed the second staff who viewed the video. This staff confirmed she worked as a Med-Tech on June 23, 2026, the following day that (R1) fell and watched the video that captured (R1) fall on June 22, 2026. This staff explained that (R1's) bed was "low to the ground" and the "rail was up" when (R1) fell out of bed. The staff provided additional details that (R1) was "sitting on the edge of their bed and tipped to the side", landing on the mat, on their side. The staff stated that the fall "didn't look serious" based on watching the video but found out (R1's) knee was "swollen the next day".

A caregiver in the MCU was asked about (R1's) recent trip to the Emergency Room (ER) on July 15, 2026 on July 23, 2026. This staff explained that (R1) "had a cast on the left leg and when we took it off, there was bleeding from an open wound- we called hospice who said to send (R1) to the ER".

The current Administrator explained that "(R1) fell in June 2026 because they got up on her own, and the floor mat sounded". The administrator explained (R1's) cast was taken off of their leg on July 15, 2026, staff saw a wound under the cast, the hospice nurse recommended (R1) be sent to the ER to be evaluated, and (R1) returned later that evening or the next day.

Resident charting notes were provided for June 2026. The notes corroborate the information obtained through interviews relating to the date of the fall, x-ray and ER visit. The notes also state that (R1) was admitted to hospice upon returning to the community on June 25, 2026 and remained on bed rest, per hospice orders. Notes made on subsequent days indicate that (R1) appeared to be comfortable, had no complaints of pain, had good food intake and staff were monitoring. On June 28, 2026, the HSD documented that (R1's) "left leg cast circulation was good".

(R1's) Care plan was updated on June 26, 2026 and notes (R1) was on a "fall management program" and needs maximum assistance with with all care needs, requires a two person transfer assist for mobility and requires moderate assistance with hospice services from the community nurse.

*cont on 9099C-3...

SUPERVISORS NAME: Lauren Crocker
LICENSING EVALUATOR NAME: Sabrina Calzada
LICENSING EVALUATOR SIGNATURE:	DATE: 09/22/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/22/2026

LIC9099 (FAS) - (06/04)

Page: 5 of 5

Control Number 59-AS-20260717121658

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: 09/22/2026

NARRATIVE

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9099C-3...LPA reviewed hospice care notes from June 29, 2026 to August 10, 2026. The notes document that on July 14, 2026, "scant bleeding" and a "small skin tear" were observed by the hospice nurse on the left knee. (R1) was sent to the ER on July 15, 2026 and wound care was provided at the facility on July 21, July 28, August 4, and on August 10 (2026), when a new wound care order was reviewed with a Med-Tech.
The "Pre-Hospital Care Report", dated June 24, 2026, documents that the ambulance service arrived and observed (R1) to be "showing discomfort on their left knee with noted swelling" and an x-ray the day prior confirmed a fracture of the left knee. (R1's) responsible person stated (R1) "was not walking" on June 22, 2026, when they fell and was not under home health or hospice either. This family member explained (R1) "had a previous fall, fractured their hip and had a partial hip replacement (R1) has not fully recovered from".

Based on information obtained, the 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.

Allegation: Facility is not providing adequate food services to residents in care. The allegation states there is still very often a noticeable difference in the quality, but mostly quantity of food in Memory Care (MCU) and Assisted Living (ALU). The facility advertises they serve dessert at dinner, but they either don't have it, or it is a small portion that they now regularly apologize for, and it’s often ice cream that (R1) enjoys.

The administrator stated on July 23, 2026, "the food portions are smaller in MCU than in ALU, commenting, "we don't want to overwhelm the residents", and confirmed MCU residents are served smoothies and snacks in between all meals on a daily basis.

All care staff and Med-Techs who were interviewed indicated that (R1) has a good appetite, with one staff stating, "Yes, (R1) has a good appetite in the morning- (R1) eats oatmeal with banana- but has more of an appetite for lunch and had 1.5 pieces of pizza and soda today".

A second staff stated "(R1) likes food and has a good appetite and the facility makes different desserts and offers ice creams to the MCU residents, and (R1) "likes ice cream and chocolate Popsicles. A third staff in MCU stated "(R1) is eating quite well" and explained that "if a resident is picky, staff will go to great lengths to find food they will eat", asserting, "with (R1), it depends on the day- (R1) will always eat French fries". This staff added, "sometimes pie is served- (R1) doesn't like pie, so we offer (R1) cake, cookies, meringues or Jell-O", commenting, "Ice cream is her favorite". *cont on 9099C-4..

SUPERVISORS NAME: Lauren Crocker
LICENSING EVALUATOR NAME: Sabrina Calzada
LICENSING EVALUATOR SIGNATURE:	DATE: 09/22/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/22/2026

LIC9099 (FAS) - (06/04)

Page: 4 of 5

Control Number 59-AS-20260717121658

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: 09/22/2026

NARRATIVE

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9099C-4... Hospice notes also document that staff indicated that (R1) is eating 75% of (3) meals on many days. (R1's) responsible stated "(R1) is well fed- maybe they run out of dessert", explaining that she regularly brings (R1) chocolate Popsicle's for her dessert.
Based on information obtained, the 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.

Allegation: Facility is not sending emails to resident's family member as requested. The allegation states for the entire time (R1) has been at the facility, they have still never set up proper communication with one of the family members, including not receiving emails, or other notifications, about the monthly events, including for this year’s 4th of July celebration and missed it.

The Activities Director, Tracy, confirmed she has worked in her current position for (3) years and sends out emails to resident families every month, which also includes flyers, a monthly calendar, and a newsletter, with each email. The Activities Director stated she also sends out a quarterly "Family Appreciation" email for the special event offered, for a total of (16) emails each year. The Director asserted that in addition to personally handing (R1's) family member the last quarter's event information, she also emailed it to him and is not receiving an email notification that the emails are "bouncing back" as not received. The Activities Director commented that this family has been on the "email list for 6 months" and was added when the prior administrator asked that he be added., and stated she forwarded the last quarterly email sent to this family member, in June 2026, to the prior administrator. One staff who was interviewed explained that "since 2023, Tracy has personally invited (R1's) family member and given him flyers for the last 1.5 years - I have witnessed Tracy personally hand the flyers to the son- he has been invited way more times than he has attended". The Administrator stated that families are welcome to visit and participate in all activities with the residents.

LPA was provided with email communication sent from the Activities Director to the family member on June 9, 2026, July 28, 2026 and the family member's response sent on July 10 that he would not be able to attend the event on June 9.
Based on information obtained, the 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. Copy of report provided.

SUPERVISORS NAME: Lauren Crocker
LICENSING EVALUATOR NAME: Sabrina Calzada
LICENSING EVALUATOR SIGNATURE:	DATE: 09/22/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/22/2026

LIC9099 (FAS) - (06/04)

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