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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 107209036
Report Date: 04/16/2024
Date Signed: 04/17/2024 08:34:38 AM


Document Has Been Signed on 04/17/2024 08:34 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1314 E SHAW AVE
FRESNO, CA 93710



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: 85DATE:
04/16/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:30 AM
MET WITH:Heidi SettyTIME COMPLETED:
05:00 PM
NARRATIVE
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Licensing Program Analysts (LPA) Katie Brown and Lissett Paggett arrived unannounced to conduct the Annual Inspection. LPA met with and explained the purpose of the visit with Administrator (AD) Heidi Setty.

During this visit, LPAs toured the facility inside & out which included multiple resident apartments in Assisted Living (AL) as well as Memory Care (MC). Resident apartments are found to be in good repair and contained required furnishings and lighting. The resident bathrooms were clean and in good repair with faucets delivering hot water within required limits. LPAs observed required hygiene items, grab bars and non skid showers. Towels, extra bedding, and linens were stored and available for use. The kitchen was clean, with necessary items and appliances. LPAs observed required food supply and paper product storage. Cleaning/disinfecting supplies and chemicals are locked and stored separate from food. Medications are centrally stored in medication rooms. First aid kits contained required items. There are multiple visitation areas available inside and out. Doors and passageways are unobstructed throughout the facility. The delayed egress doors were working properly which lead to MC. The fire detection system was last serviced 4/11/24 by Fire System Solutions, Inc. The Fire extinguishers were serviced 1/9/2024. LPAs conducted resident and staff file reviews including medication audit. Emergency Disaster Plan and Infection Control Plans were reviewed during this visit.

Deficiencies are being cited in accordance with California Code of Regulations on the attached LIC 809-D in the areas of Incidental Medical and Dental, Residents with Special Health Needs and Storage Space.


Civil Penalties are being assessed on the attached LIC421F for repeat violations.

See LIC809C for continuation of this report
SUPERVISOR'S NAME: Sergiy PidgirnyTELEPHONE: (559) 246-0610
LICENSING EVALUATOR NAME: Katie BrownTELEPHONE: (559) 498-9964
LICENSING EVALUATOR SIGNATURE:
DATE: 04/16/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/16/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 4


Document Has Been Signed on 04/17/2024 08:34 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 04/16/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87465(a)(4)
Incidental Medical and Dental Care Services
(4) The licensee shall assist residents with self-administered medications as needed.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interview and record review, the licensee did not comply with the section cited above, which poses an immediate health, safety or personal rights risk to persons in care. R5's Spiriva Respimat inhaler was not able to be located. Based on the MAR, it has been given as ordered, Centrally stored log start date is 1/29/24. The inhaler has 60 doses which means it would have run out in approximately a month. Today AM Med Tech did not assist R5 with the inhaler.
POC Due Date: 04/17/2024
Plan of Correction
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AD has agreed to provide an inservice to all Med Techs who assist with medication assistance. Inservice will include medication documentation review as well as medication assistance procedures. A written statement will be submitted to CCLD by POC date with the training plan, including dates.
Type A
Section Cited
CCR
87465(h)(2)
Incidental Medical and Dental Care Services
(h) The following requirements shall apply to medications which are centrally stored: (2) Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and record review, the licensee did not comply with the section cited above, which poses an immediate health, safety or personal rights risk to persons in care. Over the counter medications were stored in the apartment shared by R1 and R2. R2 is current in the hospital. R1 receives medication assistance by the facility, has a diagnosis of Dementia and Physician Report states R1 cannot store own medication. R4 also had medications stored in bathroom cabinets.
POC Due Date: 04/17/2024
Plan of Correction
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Medications were removed immediately from the apartment. AD agrees to provide an inservice to all staff about medication storage regulations. A written statement will be submitted to CCLD by POC date with the training plan as well as a statement as to how this will be prevented from happening again.
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: 04/16/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/16/2024
LIC809 (FAS) - (06/04)
Page: 2 of 4


Document Has Been Signed on 04/17/2024 08:34 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 04/16/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87309(a)
87309 (a) Storage Space Disinfectants, cleaning solutions, poisons, firearms and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients.
This requirement was not met as evidenced by:


Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above, which poses/posed a potential health, safety or personal rights risk to persons in care. Mold was observed in the upper portion of the ice machine. A chefs knife was observed in the prep area of the dining room with no staff member present. Disinfecting supplies were located in the bathroom cabinet of R3, who has a diagnosis of Dementia.
POC Due Date: 04/23/2024
Plan of Correction
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AD has agreed to provide inservice to applicable staff of facility storage procedures listed above. Inservice signature sheets and training materials referenced will be submitted to CCL by POC date.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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: 04/16/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/16/2024
LIC809 (FAS) - (06/04)
Page: 3 of 4


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 04/16/2024
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An exit interview was conducted and Plan of Corrections (POC) were developed. A copy of this report was signed by AD. Appeal Rights were also provided.

LPA requested the following updated forms faxed to CCLD by 4/4/2024: Designation of Facility Responsibility (Lic308), Administrative Organization (Lic309), Affidavit Regarding Client/Resident Cash Resources (LIC 400), Emergency Disaster Plan (LIC610E), Personnel Report (LIC 500), Client Roster (LIC 9020), Proof of current Liability Coverage.

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

DATE: 04/16/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/16/2024
LIC809 (FAS) - (06/04)
Page: 4 of 4