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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 107209036
Report Date: 08/30/2023
Date Signed: 08/30/2023 04:08:33 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, 1314 E SHAW AVE
FRESNO, CA 93710
This is an official report of an unannounced visit/investigation of a complaint received in our office on
05/16/2023 and conducted by Evaluator Katie Brown
PUBLIC
COMPLAINT CONTROL NUMBER: 24-AS-20230516174446
FACILITY NAME:OAKMONT OF NORTH FRESNOFACILITY NUMBER:
107209036
ADMINISTRATOR:GUSTIN, PATRICIAFACILITY TYPE:
740
ADDRESS:5605 N GATES AVETELEPHONE:
(559) 277-5959
CITY:FRESNOSTATE: CAZIP CODE:
93722
CAPACITY:122CENSUS: 76DATE:
08/30/2023
UNANNOUNCEDTIME BEGAN:
03:06 PM
MET WITH:Heidi SettyTIME COMPLETED:
04:30 PM
ALLEGATION(S):
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The facility did not conduct an assessment of resident prior to returning from the hospital with a change of condition
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Katie Brown arrived at the facility to deliver complaint investigation findings. LPA met with Administrator (AD) Heidi Setty.

Resident (R1) fell resulting in a fracture requiring surgery on 5/1/23. Based on interview, it was confirmed that the facility did not conduct an assessment or obtain required updated documentation of R1’s changes in condition or care needs prior to return to the facility on 5/6/23.

Deficiencies are being cited in accordance with California Code of Regulations on the attached LIC 809-D.

An exit interview was conducted and Plan of Correction was developed. A copy of this report and Appeal Rights were discussed and left with AD, whose signature on this form confirms receipt of these documents.



Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Sergiy PidgirnyTELEPHONE: (559) 246-0610
LICENSING EVALUATOR NAME: Katie BrownTELEPHONE: (559) 498-9964
LICENSING EVALUATOR SIGNATURE:

DATE: 08/30/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/30/2023
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 4
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1314 E SHAW AVE
FRESNO, CA 93710
This is an official report of an unannounced visit/investigation of a complaint received in our office on
05/16/2023 and conducted by Evaluator Katie Brown
PUBLIC
COMPLAINT CONTROL NUMBER: 24-AS-20230516174446

FACILITY NAME:OAKMONT OF NORTH FRESNOFACILITY NUMBER:
107209036
ADMINISTRATOR:GUSTIN, PATRICIAFACILITY TYPE:
740
ADDRESS:5605 N GATES AVETELEPHONE:
(559) 277-5959
CITY:FRESNOSTATE: CAZIP CODE:
93722
CAPACITY:122CENSUS: 76DATE:
08/30/2023
UNANNOUNCEDTIME BEGAN:
03:06 PM
MET WITH:Heidi SettyTIME COMPLETED:
04:30 PM
ALLEGATION(S):
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9
1. Resident fell and sustained a fracture due to lack of supervision.
2. Staff did not properly address resident's multiple falls at facility.
3. Licensee dos not ensure resident has a signal system that operates from
their living unit.
4. Staff did not inform resident's authorized representative of incidents
involving resident.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Katie Brown arrived at the facility to deliver complaint investigation findings. LPA met with Administrator (AD) Heidi Setty.

1. Based on interview, care staff responded to hearing R1 yelling for help from R1’s room. Staff found R1 sitting on the floor, this was an unwitnessed fall. Record review of R1’s Individualized Service Plan, R1 was identified as a risk for falls. The plan also notes that R1 is reluctant to ask for assistance and ambulated using a cane.
2. Interviews reveal that after a resident falls, facility procedure is to place resident on alert charting (increased monitoring). The facility provided alert charting documentation and a revised Needs & Service Plan dated 5/10/23 after R1 returned post hospitalization and surgery. The facility did not produce documentation of specific fall prevention measures as R1 continued to experience un-witnessed falls though staff interviews state measures were in place.
SEE LIC9099-C FOR REPORT CONTINUATION










Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Sergiy PidgirnyTELEPHONE: (559) 246-0610
LICENSING EVALUATOR NAME: Katie BrownTELEPHONE: (559) 498-9964
LICENSING EVALUATOR SIGNATURE:

DATE: 08/30/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/30/2023
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 4
Control Number 24-AS-20230516174446
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1314 E SHAW AVE
FRESNO, CA 93710
FACILITY NAME: OAKMONT OF NORTH FRESNO
FACILITY NUMBER: 107209036
VISIT DATE: 08/30/2023
NARRATIVE
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3. Based on interviews, conflicting information was received relating to whether the facility notified the Responsible Party of all incidents which occurred. Record reviews of Incident Reports and facility Chart Notes note the “RP was notified”. It was discovered that the facility would notify both the responsible party/POA and other times another family member would be notified in person during a visit.

4. Based on observation and interviews, rooms in Memory Care have a call button in the restroom. Rooms in Memory Care have a motion sensor alert system. Based on interview of R1 and record review, it is unable to be determined if R1 understood how to use the call system or that the bathroom alert was in place.

The above allegations (#1 - 4) are UNSUBSTANTIATED. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove that the alleged violations did or did not occur.

There were no citations issued

An exit interview was conducted and a copy of this report was left with AD, whose signature confirms receipt of these documents.
SUPERVISOR'S NAME: Sergiy PidgirnyTELEPHONE: (559) 246-0610
LICENSING EVALUATOR NAME: Katie BrownTELEPHONE: (559) 498-9964
LICENSING EVALUATOR SIGNATURE:

DATE: 08/30/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/30/2023
LIC9099 (FAS) - (06/04)
Page: 3 of 4
Control Number 24-AS-20230516174446
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1314 E SHAW AVE
FRESNO, CA 93710

FACILITY NAME: OAKMONT OF NORTH FRESNO
FACILITY NUMBER: 107209036
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/30/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/06/2023
Section Cited
CCR
87463(a)(3)
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87463 Reappraisals (a) The pre-admission appraisal shall be updated, in writing as frequently as necessary to note significant changes ... The reappraisals shall document changes in the resident's physical, medical,(3) Any illness, injury, trauma, or change in the health care needs…
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AD has agreed to review and update the procedure of communication, assessment and return of residents from the hospital. The procedure will include communication with and coordination of Home Health Services if applicable.
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This requirement was not met as evidenced by: R1 was accepted back to the facility with a significant change prior to the facility conducting an assessment or Home Health plan of care in place. This poses a potential health & safety risk to persons in care.
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This procedure and proof of training will be emailed to CCL by the POC date.
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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: Sergiy PidgirnyTELEPHONE: (559) 246-0610
LICENSING EVALUATOR NAME: Katie BrownTELEPHONE: (559) 498-9964
LICENSING EVALUATOR SIGNATURE:

DATE: 08/30/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/30/2023
LIC9099 (FAS) - (06/04)
Page: 4 of 4