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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079201083
Report Date: 10/03/2024
Date Signed: 10/03/2024 02:25:53 PM

Document Has Been Signed on 10/03/2024 02:25 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME:MONTECITO OAKMONT SENIOR LIVINGFACILITY NUMBER:
079201083
ADMINISTRATOR/
DIRECTOR:		SAMANIEGO, AGUSTINFACILITY TYPE:
740
ADDRESS:4756 CLAYTON ROADTELEPHONE:
(925) 692-5838
CITY:CONCORDSTATE: CAZIP CODE:
94521
CAPACITY: 230CENSUS: 170DATE:
10/03/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:15 AM
MET WITH:Ric Pielstick, Executive Director
Maria Tejano, Health Service Director		TIME VISIT/
INSPECTION COMPLETED:
02:40 PM
NARRATIVE
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On 10/3/2024 at 11:15AM, Licensing Program Analyst (LPA) G. Luk arrived unannounced to conduct a case management visit in regards to incident report received on 9/19/2024. LPA met with Executive Director, Ric Pielstick and informed him the reason for the visit. LPA later met with Health Service Director, Maria Tejano.

Based on the incident report received on 9/19/2024, resident (R1) was given the incorrect medications. Facility staff immediately monitored R1 for any adverse drug reactions and vital signs were obtained. R1's family and doctor was immediately notified.

During visit, LPA interview 3 staff and reviewed R1's file including physician's report, medication list, care notes, incident report, and training information. Care notes stated that R1 did not have adverse drug interaction during incident. LPA observed staff (S3) had online medication training. However, facility was not able to provide hands on shadowing training documents during visit.

The deficiencies were observed (see LIC 809D) and cited from the California Code of Regulation, Title 22 and Health & Safety Code. Failure to correct the deficiencies may result in civil penalties.

Exit interview conducted with Maria Tejano. A copy of this report and appeal rights provided.
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Grace Luk
LICENSING EVALUATOR SIGNATURE: DATE: 10/03/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/03/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2
Document Has Been Signed on 10/03/2024 02:25 PM - It Cannot Be Edited


Created By: Grace Luk On 10/03/2024 at 01:36 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: MONTECITO OAKMONT SENIOR LIVING
FACILITY NUMBER: 079201083

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/03/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
10/04/2024
Section Cited
CCR
87465(a)(4)

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Incidental Medical and Dental Care. The licensee shall assist residents with self-administered medications as needed. This requirement is not met as evidence by:
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Facility has conducted additional training for staff (S3) and provided documents to LPA during visit. 10/9/2024, facility will conduct a med pass audit and will be conducted by pharmacy nurse.
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Based on interview and record review, licensee did not comply with the section cited above by not administering the correct medications to R1 which poses an immediate health and safety risk to the persons in care.
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Additionally, facility provided medication error prevention training document during visit.

Deficiency cleared.
Type B
10/18/2024
Section Cited
HSC1569.69(a)(1)

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Employees assisting residents with self-administration of medication; training requirements...This training shall consist of 16 hours of hands-on shadowing...
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Facility has provided medication training documents during visit.
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This requirement is not met as evidence by: Based on interview and record review, licensee did not comply with the section cited above by staff not completing hands on shadowing training which poses a potential health and safety risk to the persons in care.
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Deficiency cleared.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Harpreet Humpal
LICENSING EVALUATOR NAME:Grace Luk
LICENSING EVALUATOR SIGNATURE:
DATE: 10/03/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/03/2024


LIC809 (FAS) - (06/04)
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