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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 107209036
Report Date: 01/12/2024
Date Signed: 01/12/2024 02:11:20 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
09/11/2023 and conducted by Evaluator Katie Brown
PUBLIC
COMPLAINT CONTROL NUMBER: 24-AS-20230911151045
FACILITY NAME:OAKMONT OF NORTH FRESNOFACILITY NUMBER:
107209036
ADMINISTRATOR:SETTY, HEIDIFACILITY TYPE:
740
ADDRESS:5605 N GATES AVETELEPHONE:
(559) 277-5959
CITY:FRESNOSTATE: CAZIP CODE:
93722
CAPACITY:122CENSUS: 82DATE:
01/12/2024
UNANNOUNCEDTIME BEGAN:
09:10 AM
MET WITH:Heidi Setty TIME COMPLETED:
12:30 PM
ALLEGATION(S):
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Resident fell due to staff neglect
Staff did not prevent resident from wandering from the facility
Facility did not report a resident fall
INVESTIGATION FINDINGS:
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Licensing Program Analyst(LPA) Katie orwn arrived at the facility unannounced to deliver the complaint findings. LPA met with Administrator (AD) Heidi Setty. The Department investigated the allegations listed above.

Interviews and record review of R1’s hospice care plan and facility documentation reveal that on 3/10/23, R1’s hospice care plan was not followed resulting in R1 falling while being assisted by hospice aid and facility care staff. The care plan (certification period 2/3/23 – 3/30/23) notes that R1 will receive a bed bath.

On 10/10/22, Resident (R2) was located by staff after exiting the facility resulting in Absence Without Leave (AWOL). R2 was found walking down the street off facility grounds. R2’s Physician’s Report dated 4/29/22 states R2 cannot leave the facility unassisted.

See Lic9099C for continuation of this report
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: 01/12/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/12/2024
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 6
Control Number 24-AS-20230911151045
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: 01/12/2024
NARRATIVE
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Interview and record review of facility documentation of the incident reveal that R1 experienced a fall in the shower while being assisted by hospice aid and facility care provider. Written statements from both as well as the chart note by Med Tech include that R1’s head came in contact with the wall during a fall. The facility did not report the incident to CCLD as required.


Deficiencies are being cited in accordance with California Code of Regulations on the attached LIC 9099-D in the areas of Personnel Requirements, Hospice Care of Terminally Ill Residents and Reporting Requirements.



An exit interview was conducted and Plan of Correction was developed. A copy of this report and Appeal Rights were signed and emailed to AD Hsetty@oakmontmg.com..
SUPERVISOR'S NAME: Sergiy PidgirnyTELEPHONE: (559) 246-0610
LICENSING EVALUATOR NAME: Katie BrownTELEPHONE: (559) 498-9964
LICENSING EVALUATOR SIGNATURE:

DATE: 01/12/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/12/2024
LIC9099 (FAS) - (06/04)
Page: 4 of 6
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
09/11/2023 and conducted by Evaluator Katie Brown
PUBLIC
COMPLAINT CONTROL NUMBER: 24-AS-20230911151045

FACILITY NAME:OAKMONT OF NORTH FRESNOFACILITY NUMBER:
107209036
ADMINISTRATOR:SETTY, HEIDIFACILITY TYPE:
740
ADDRESS:5605 N GATES AVETELEPHONE:
(559) 277-5959
CITY:FRESNOSTATE: CAZIP CODE:
93722
CAPACITY:122CENSUS: 82DATE:
01/12/2024
UNANNOUNCEDTIME BEGAN:
09:10 AM
MET WITH:Heidi SettyTIME COMPLETED:
12:30 PM
ALLEGATION(S):
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Questionable death
Staff did not notify resident's authorized representative of incident in a timely manner
Basic Activities of Daily Living needs were not provided
Staff did meet resident's testing needs
INVESTIGATION FINDINGS:
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Licensing Program Analyst(LPA) Katie orwn arrived at the facility unannounced to deliver the complaint findings. LPA met with Administrator (AD) Heidi Setty. The Department investigated the allegations listed above.

R1’s Death Certificate was obtained and reveals that immediate cause of death on 3/31/23 was not related to a fall. R1 was receiving hospice care at the facility. Record review of R1’s facility and hospice file were reviewed during the investigation. R1 experienced a fall on 3/10/23. R1 was not evaluated in the hospital post fall and a nurse evaluation or notes were not discovered for review.

Based on record review and interview, the Department is not able to determine what time the Authorized Representative was notified after R2 was discovered to have left the facility unassisted (AWOL). Interviews and facility documentation reveal conflicting timelines.

See Lic9099C for continuation of this report
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: 01/12/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/12/2024
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 6
Control Number 24-AS-20230911151045
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: 01/12/2024
NARRATIVE
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Based on observation, interview, and record review the Department is unable to determine if Activities of Daily Living (ADLs) and basic services were provided to R2. LPA visited the facility multiple times between 9/12/23 and 12/12/23 and observed water available during and in between meals as well as residents being assisted to eat. Record review of facility chart notes and emails show that between 3/8/23 – 4/8/23 housekeeping and hands on care service was increased for R2 due to increased need. This additional care was suspended 4/8/23. Hospice records do not mention basic services not being provided. Hospice records document that R2 continued to lose weight between 10/2022 – 8/2023 related to disease process and minimal/poor food intake.

Based on record review, an order was written for R2 to receive weekly routine lab work on 7/18/22. R2 was admitted to hospice 10/25/23. R2's facility and hospice records were obtained and reviewed. It is not able to be determined when or if this routine order was discontinued. Additionally, the hospice agency ordered lab work to be done 3/14/23 which was scheduled by the facility to be completed 3/20/23. The hospice agency revised that order for the lab work to be conducted sooner by a mobile service.

Based on interview, record review and observation, the above allegations 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 signed by AD and emailed to HSetty@oakmontmg.com
SUPERVISOR'S NAME: Sergiy PidgirnyTELEPHONE: (559) 246-0610
LICENSING EVALUATOR NAME: Katie BrownTELEPHONE: (559) 498-9964
LICENSING EVALUATOR SIGNATURE:

DATE: 01/12/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/12/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 6
Control Number 24-AS-20230911151045
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: 01/12/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
01/15/2024
Section Cited
CCR
87633(a)(4)
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87633 Hospice Care of Terminally Ill Residents (a) The licensee shall be permitted... receive hospice services from a hospice agency in the facility…(4) A written hospice care plan which specifies the care, services... all hospice care plans are fully implemented by the licensee and by the hospice(s).
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AD has agreed to provide a written statement which will include the review and in-service plan which will be completed by the facility. The statement will be submitted by 5pm 1/15/24.
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This requirement was not met as evidenced by: Licensee did not ensure R1's hospice care plan was implemented. R1 received a shower by staff and hospice aid of the wrong agency. R1's careplan specifies a bed bath to be given. R1 sustained a fall during this shower.
This poses an immediate health & safety risk to persons in care.
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AD has agreed that all appropriate staff will recieve in-service on the individualized hospice care plans and to ensure proper communication between staff communication. A signed in-service will be submitted to CCLD via email by the POC date.
Type A
01/15/2024
Section Cited
CCR
87411(d)(3)
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87411 Personnel Requirements – General(d) All personnel shall be given on the job training…training shall provide knowledge of and skill in the following, as appropriate for the job assigned and as evidenced by safe and effective job performance: (3) Skill and knowledge required to provide necessary resident care and supervision...,
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AD has agreed to provide a written statement which will include the review and in-service plan which will be completed by the facility. The statement will be submitted by 5pm 1/15/24.
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This requirement was not met as evidenced by: Licensee did not ensure supervision of R2 who exited the Dementia wing and walked out of the facility on 3/10/23. R1's whereabouts were unknown by the facility. This poses an immediate health & safety risk to persons in care.
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AD has agreed to conduct an elopement drill for all shifts. A sign in sheet will be submitted to ccld once all appropriate staff have reviewed and practiced elopement procedures. Facility conducted elopement inservice on 12/28/23. Sign in will be emailed to ccld by POC date.
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: 01/12/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/12/2024
LIC9099 (FAS) - (06/04)
Page: 5 of 6
Control Number 24-AS-20230911151045
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: 01/12/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Deficiency Dismissed
Type B
01/22/2024
Section Cited
CCR
87411(a)(1)(D)
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87211 Reporting Requirements (a) Each licensee shall furnish to the licensing agency such reports… (1) A written report shall be submitted… (D) Any incident which threatens the welfare, safety or health of any resident…

This requirement was not met as evidenced by:
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AD has agreed to review the facility reporting procedure with the other Directors involved. A written statement will be submitted to include revised evaluation process of determining what incidents are reported to CCLD.
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Licensee did not ensure an Incident Report was submitted to CCLD when R1 fell and hit head while receiving a shower by the wrong hospice agency and facility staff member.

This poses a potential health & safety risk to persons in care
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AD and Directors will sign the statement which will be emailed to CCLD by 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: 01/12/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/12/2024
LIC9099 (FAS) - (06/04)
Page: 6 of 6