079200925-5-17-2022-15-AS-KHOS-CG2LKZ-20220705085022

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 079200925
Report Date: 05/17/2022
Date Signed: 05/17/2022 03:18:28 PM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

This is an official report of an unannounced visit/investigation of a complaint received in our office on
05/21/2021 and conducted by Evaluator Leslie Ibo

COMPLAINT CONTROL NUMBER: 15-AS-20210521143830

FACILITY NAME:	OAKMONT OF CONCORD		FACILITY NUMBER:	079200925
ADMINISTRATOR:	ANGELES STICKA		FACILITY TYPE:	740
ADDRESS:	1401 CIVIC COURT		TELEPHONE:	(925) 798-4004
CITY:	CONCORD	STATE: CA	ZIP CODE:	94520
CAPACITY:	0	CENSUS: 85	DATE:	05/17/2022
		UNANNOUNCED	TIME BEGAN:	10:15 AM
MET WITH:	Julis Osorio, Operation Specialist		TIME COMPLETED:	12:30 PM

ALLEGATION(S):

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Facility not adhering to visitation schedule
Staff failed to prevent bed sores

INVESTIGATION FINDINGS:

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On 5/17/2022 Licensing Program Analysts (LPA) L. Ibo arrived unannounced to deliver complaint findings for the above allegation. LPA met with Julius Osorio, Interim Executive director and explained the purpose of the visit.

Allegation: Facility not adhering to visitation schedule
During the course of investigation, facility was following PIN 20-38-ASC, based on interview conducted facility had a scheduling system where non-essential visit needs to be scheduled 24 hours in advance. This helped the facility monitored the incoming and outgoing visits and enough time to clean the visitation area. Currently facility is open for visitors essential and non-essential visitation.

...Continue on LIC9099-C

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Harpreet Humpal	TELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Leslie Ibo	TELEPHONE: 510-286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 05/17/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/17/2022

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 3

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

This is an official report of an unannounced visit/investigation of a complaint received in our office on
05/21/2021 and conducted by Evaluator Leslie Ibo

COMPLAINT CONTROL NUMBER: 15-AS-20210521143830

FACILITY NAME:	OAKMONT OF CONCORD		FACILITY NUMBER:	079200925
ADMINISTRATOR:	ANGELES STICKA		FACILITY TYPE:	740
ADDRESS:	1401 CIVIC COURT		TELEPHONE:	(925) 798-4004
CITY:	CONCORD	STATE: CA	ZIP CODE:	94520
CAPACITY:	0	CENSUS: 85	DATE:	05/17/2022
		UNANNOUNCED	TIME BEGAN:	10:15 AM
MET WITH:	Julius Osorio, Operation Specialist		TIME COMPLETED:	12:30 PM

ALLEGATION(S):

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Facility does not have fully functioning phone
Facility denied resident furnishings

INVESTIGATION FINDINGS:

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On 5/17/2022 Licensing Program Analysts (LPA) L. Ibo arrived unannounced to deliver complaint findings for the above allegation. LPA met with Julius Osorio, Interim Executive director and explained the purpose of the visit.

During the course of the investigation, LPA called facility phone number and observed to be fully functional and can also transferred to memory care department.
Allegation: Facility denied resident furnishings
Based on observation, LPA observed appropriate furnishing based on regulations. LPA also observed that R1,R2, R5 have their own television , R3 has no television but resident preferred radio instead of television.

Based on information gathered, the allegation is UNFOUNDED. A finding that the complaint is unfounded means that the allegation is false, could not have happened, and/or is without a reasonable basis.
Exit interview with conducted and a copy of this report provided.

Unfounded

Estimated Days of Completion:

SUPERVISOR'S NAME: Harpreet Humpal	TELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Leslie Ibo	TELEPHONE: 510-286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 05/17/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/17/2022

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

Page: 2 of 3

Control Number 15-AS-20210521143830

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: OAKMONT OF CONCORD	FACILITY NUMBER: 079200925
	VISIT DATE: 05/17/2022

NARRATIVE

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Allegation: Staff failed to prevent bed sores

Based on records review, on 5/19/2021 R1 started to have redness on his buttocks, facility staff immediately informed R1’s physician about the resident’s condition. R1’s physician prescribed medication and facility staff continued to monitor resident. Based on records review, staff requested R1’s physician to order home health nurse to address R1’s wound, staff continued to send any change of condition to R1’s physician and representative.

Based on interviews conducted and records reviewed, the preponderance of evidence standard has not been met, therefore the allegation is found to be UNSUBSTANTIATED, meaning that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove it did or did not occur.

Exit interview conducted and a copy of this report provided.

SUPERVISOR'S NAME: Harpreet Humpal	TELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Leslie Ibo	TELEPHONE: 510-286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 05/17/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/17/2022

LIC9099 (FAS) - (06/04)

Page: 3 of 3