079201085-1-19-2023-15-AS-KHOS-CP2SD8-20230214124642

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 079201085
Report Date: 01/19/2023
Date Signed: 01/19/2023 01:11:32 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
10/20/2021 and conducted by Evaluator Lizette Francisco

PUBLIC

COMPLAINT CONTROL NUMBER: 15-AS-20211020151456

FACILITY NAME:	OAKMONT OF CONCORD		FACILITY NUMBER:	079201085
ADMINISTRATOR:	STICKA, ANGELES		FACILITY TYPE:	740
ADDRESS:	1401 CIVIC COURT		TELEPHONE:	(925) 798-4004
CITY:	CONCORD	STATE: CA	ZIP CODE:	94520
CAPACITY:	121	CENSUS: 85	DATE:	01/19/2023
		UNANNOUNCED	TIME BEGAN:	09:50 AM
MET WITH:	Susana Chavez, Memory Care Director		TIME COMPLETED:	01:25 PM

ALLEGATION(S):

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Staff are not allowing resident to visit with family member.
Resident has an unexplained injury.
Staff do not ensure resident has his glasses.

INVESTIGATION FINDINGS:

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On 1/19/2023 starting at 9:50 AM, Licensing Program Analysts (LPAs) L. Francisco and P. Watson arrived unannounced to deliver findings for the above allegations. LPAs met with Memory Care Director, Susana Chavez and explained the purpose of the visit.

During the course of the investigation, LPA L. Francisco obtained information, reviewed records, collected documents, and interviewed staff, residents and family members. It was alleged staff are not allowing resident to visit with family member. Based on interview with family members (F1, F2 and F3), facility was allowing family members to visit residents. During an interview with S1 and S2, LPAs discovered facility issued guidance for visitors to schedule appointments for in-person visitation sometime in 2020 to control the amount of visitors that come into the facility all at once. If visitors were running late, then they are provided an alternative options such as a different time on the same day, video call or phone call.

REPORT CONTINUES ON 9099C

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Harpreet Humpal	TELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Lizette Francisco	TELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 01/19/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/19/2023

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

LIC9099 (FAS) - (06/04)

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Control Number 15-AS-20211020151456

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: 079201085
	VISIT DATE: 01/19/2023

NARRATIVE

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It was alleged resident has an unexplained injury. Based on information obtained by reporting party, resident (R1) had missing teeth. However, interview with S2 and S3, revealed that R1 had extractions completed. F1 stated R1 is seen by a dental hygienist every two months and provides recommendation of dental work that is needed.

It was alleged staff do not ensure resident has his glasses. However, based on interview with S2 and S3, R1 has a habit of removing glasses after staff puts it on. According to F1, R1's optometrist stated R1 does not really need glasses.

Although the allegations may have happened or are valid, there are not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegations are UNSUBSTANTIATED.

Exit interview conducted and a copy of this report provided to Memory Care Director.

SUPERVISOR'S NAME: Harpreet Humpal	TELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Lizette Francisco	TELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 01/19/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/19/2023

LIC9099 (FAS) - (06/04)

Page: 2 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
10/20/2021 and conducted by Evaluator Lizette Francisco

COMPLAINT CONTROL NUMBER: 15-AS-20211020151456

FACILITY NAME:	OAKMONT OF CONCORD		FACILITY NUMBER:	079201085
ADMINISTRATOR:	STICKA, ANGELES		FACILITY TYPE:	740
ADDRESS:	1401 CIVIC COURT		TELEPHONE:	(925) 798-4004
CITY:	CONCORD	STATE: CA	ZIP CODE:	94520
CAPACITY:	121	CENSUS:	DATE:	01/19/2023
		UNANNOUNCED	TIME BEGAN:	09:50 AM
MET WITH:	Susana Chavez, Memory Care Director		TIME COMPLETED:	01:25 PM

ALLEGATION(S):

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Staff will not allow the resident to have a TV.

INVESTIGATION FINDINGS:

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On 1/19/2023 starting at 9:50 AM, Licensing Program Analysts (LPAs) L. Francisco and P. Watson arrived unannounced to delivery findings for the above allegations. LPAs met with Memory Care Director, Susana Chavez and explained the purpose of the visit.

During the course of the investigation, LPA L. Francisco obtained information, reviewed records, collected documents, and interviewed staff and family members. It was alleged staff will not allow resident to have a TV. However, during LPA L. Francisco's tour on 10/28/2021, LPA observed a TV in R1's room.

This agency has investigated the complaint alleging staff will not allow the resident to have a TV. We have found that the complaint was UNFOUNDED, meaning that the allegation was false, could not have happened and/or is without a reasonable basis.

Exit interview conducted. A copy of this report provided to Memory Care Director.

Unfounded

Estimated Days of Completion:

SUPERVISOR'S NAME: Harpreet Humpal	TELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Lizette Francisco	TELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 01/19/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/19/2023

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 3