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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 107209036
Report Date: 11/06/2023
Date Signed: 11/06/2023 04:14:44 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
08/01/2023 and conducted by Evaluator Katie Brown
PUBLIC
COMPLAINT CONTROL NUMBER: 24-AS-20230801083339
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: 89DATE:
11/06/2023
UNANNOUNCEDTIME BEGAN:
08:47 AM
MET WITH:Mary DavisTIME COMPLETED:
04:20 PM
ALLEGATION(S):
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Staff mismanaged resident's medications.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Katie Brown arrived at the facility unannounced to conduct a subsequent complaint visit. Administrator (AD) was not at the facility for the visit. LPA met with and explained the reason for the visit with Marketing Director (MD)Mary Davis.

During the visit, LPA obtained additional documents from Resident (R1’s) file and conducted a record review.The Department investigated the allegation above. LPA conducted a record review of R1’s Facility Chart Notes, Centrally Stored Medication & Destruction Record (CSMDR) and Medication Administration Records (MAR) during the timeframe of April - August 2023. Based on record review, it was identified that the CSMDR for R1 was not maintained resulting in inaccurate documentation and medication counts. The preponderance of evidence standard has been met, therefore the above allegations are found to be SUBSTANTIATED.

A deficiency is being cited in accordance with California Code of Regulations on the attached LIC 9099-D.
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: 11/06/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/06/2023
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 5
Control Number 24-AS-20230801083339
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: 11/06/2023
NARRATIVE
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An exit interview was conducted and Plan of Correction was developed. A copy of this report and Appeal Rights were discussed and left with MD, whose signature on this form 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: 11/06/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/06/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 5
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
08/01/2023 and conducted by Evaluator Katie Brown
PUBLIC
COMPLAINT CONTROL NUMBER: 24-AS-20230801083339

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: 89DATE:
11/06/2023
UNANNOUNCEDTIME BEGAN:
08:47 AM
MET WITH:Mary DavisTIME COMPLETED:
04:20 PM
ALLEGATION(S):
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Incidents are not reported accurately.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Katie Brown arrived at the facility unannounced to conduct a subsequent complaint visit. Administrator (AD) was not at the facility for the visit. LPA met with and explained the reason for the visit with Marketing Director (MD) Mary Davis.

The Department investigated the allegation above. LPA reviewed R1’s Facility Chart notes and Special Incident Reports (SIRs) which were submitted. Based on the record review, it was identified that an incident which occurred on 6/15/23 was inconsistently documented internally and to family. The incident was reported to required parties and R1 was placed on alert charting per facility procedure post fall. Chart notes were found to record a day to day record of R1 in the non-medical RCFE setting. The above allegation is UNSUBSTANTIATED. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove that the alleged violation did or did not occur.

There were no citations issued


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: 11/06/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/06/2023
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 5
Control Number 24-AS-20230801083339
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: 11/06/2023
NARRATIVE
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An exit interview was conducted and a copy of this report was left with MD, 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: 11/06/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/06/2023
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 24-AS-20230801083339
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: 11/06/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
11/14/2023
Section Cited
CCR
87465(a)(6)
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87465 Incidental Medical and Dental Care (a) A plan for incidental medical and dental care shall be developed by each facility… by compliance with the following: (6) When requested... or the Department, a record of dosages of medications which are centrally stored shall be maintained by the facility. This requirement was not met as evidenced by:
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AD has agreed to provide an inservice to appropriate staff which reviews the procedure for centrally stored medication acceptance and documentation. A sign in sheet will be submitted which records the training agenda as well as name and signature of staff attending the inservice.
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Licensee did not ensure that a record was maintained of medications that were centrally stored for R1. Multiple medications were accepted and stored by the facility but an accurate/up to date Centrally Stored Medication and Destruction Record (CSMDR) was not maintained. Received and start dates are not recorded for multiple medications from April-August 2023. This poses a potential health & safety risk to persons in care.

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The sign in sheet and supporting materials used will be submitted to CCLD via email 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: 11/06/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/06/2023
LIC9099 (FAS) - (06/04)
Page: 5 of 5