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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 092700750
Report Date: 08/11/2022
Date Signed: 08/11/2022 12:36:08 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 520 COHASSET RD., STE. 170
CHICO, CA 95926
This is an official report of an unannounced visit/investigation of a complaint received in our office on
10/14/2021 and conducted by Evaluator DeAnna Williams-Lyons
PUBLIC
COMPLAINT CONTROL NUMBER: 25-AS-20211014164117
FACILITY NAME:OAKMONT OF EL DORADO HILLSFACILITY NUMBER:
092700750
ADMINISTRATOR:YOUNAN, HEATHERFACILITY TYPE:
740
ADDRESS:2020 TOWN CENTER WEST WAYTELEPHONE:
(916) 467-8330
CITY:EL DORADO HILLSSTATE: CAZIP CODE:
95762
CAPACITY:129CENSUS: 80DATE:
08/11/2022
UNANNOUNCEDTIME BEGAN:
11:33 AM
MET WITH:Kathleen Olson, Executive DirectorTIME COMPLETED:
12:15 PM
ALLEGATION(S):
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Facility made medication administration errors
Facility is not releasing medical records upon request
INVESTIGATION FINDINGS:
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On August 11, 2022, Licensing Program Analyst (LPA) DeAnna Williams-Lyons arrived unannounced to deliver findings for Complaint 25-AS-20211014164117. LPA met with Kathleen Olson, Executive Director and explained the reason for the visit. Prior to the visit, LPA conducted COVID -19 Precautionary prescreening and wore a surgical mask while at the facility and was also screened by front desk personnel. LPA investigated the allegation of “Facility made medication administration errors” and interviewed the Executive Director, Resident, Witnesses, and reviewed facility and complainant’s documentation.

Based on record review, facility staff administered one (1) medication for R1 at incorrect times during August 2021 (Approximately 17 days) and facility staff listed one (1) medication for R1 as a PRN when physician orders listed medication as a daily medication. The facility conducted an internal audit of R1’s medications and needs and service plan. As of this date, facility is administering R1’s medications as prescribed.
to continue see 9099C...
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Laura MunozTELEPHONE: (916) 263-4743
LICENSING EVALUATOR NAME: DeAnna Williams-LyonsTELEPHONE: (916) 212-3983
LICENSING EVALUATOR SIGNATURE:

DATE: 08/11/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/11/2022
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
Control Number 25-AS-20211014164117
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 520 COHASSET RD., STE. 170
CHICO, CA 95926
FACILITY NAME: OAKMONT OF EL DORADO HILLS
FACILITY NUMBER: 092700750
VISIT DATE: 08/11/2022
NARRATIVE
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Based on records reviewed, facility staff made medication administrator error’s with R1 medications therefore the complaint is SUBSTANTIATED, which means the preponderance of evidence standards has been met.

Per California Code of Regulations, Title 22 Division 6, Chapter 8, deficiencies are being cited on the attached 9099 D during this visit. Exit interview held, Appeal Rights discussed, copy of report given.
SUPERVISOR'S NAME: Laura MunozTELEPHONE: (916) 263-4743
LICENSING EVALUATOR NAME: DeAnna Williams-LyonsTELEPHONE: (916) 212-3983
LICENSING EVALUATOR SIGNATURE:

DATE: 08/11/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/11/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 25-AS-20211014164117
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 520 COHASSET RD., STE. 170
CHICO, CA 95926

FACILITY NAME: OAKMONT OF EL DORADO HILLS
FACILITY NUMBER: 092700750
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/11/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Deficiency Dismissed
Type A
08/11/2022
Section Cited
CCR
87456
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Incidental Medical and Dental Care
(c)If the resident's physician has stated in writing that the resident is unable to determine his/her own need for nonprescription PRN medication but can communicate his/her symptoms clearly, facility staff designated by the licensee shall be permitted to assist the resident with self-administration, provided all of the following requirements are met: (2) Once ordered by the physician the medication is given according to the physician's directions
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Facility will ensure resident medication orders are correctly imputed into the facility E-MAR system and followed by medication staff.
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shall be permitted to assist the resident with self-administration, provided all of the following requirements are met: (2) Once ordered by the physician the medication is given according to the physician's directions
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08/11/2022
Section Cited
CCR
87456
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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: Laura MunozTELEPHONE: (916) 263-4743
LICENSING EVALUATOR NAME: DeAnna Williams-LyonsTELEPHONE: (916) 212-3983
LICENSING EVALUATOR SIGNATURE:

DATE: 08/11/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/11/2022
LIC9099 (FAS) - (06/04)
Page: 3 of 3