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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 312700863
Report Date: 08/02/2022
Date Signed: 08/02/2022 10:45:25 AM


Document Has Been Signed on 08/02/2022 10:45 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, 520 COHASSET RD., STE. 170
CHICO, CA 95926



FACILITY NAME:OAKMONT OF WESTPARKFACILITY NUMBER:
312700863
ADMINISTRATOR:ATONETTE EDWARDSFACILITY TYPE:
740
ADDRESS:2400 PLEASANT GROVE BLVDTELEPHONE:
(916) 789-2000
CITY:ROSEVILLESTATE: CAZIP CODE:
95747
CAPACITY:142CENSUS: 101DATE:
08/02/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
10:25 AM
MET WITH:Antonette Edwards TIME COMPLETED:
11:00 AM
NARRATIVE
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Licensing Program Analyst (LPA) Talwinder Bains arrived at the facility unannounced on 08/02/22 to conduct a case management inspection to follow up on a recent AWOL at the facility. LPA met with facility Executive Director (ED)- Antonette Edwards and explained the purpose of the visit. Prior to initiating the visit , LPA completed required COVID-19 testing protocols, the daily self-screening questionnaire for symptoms of COVID-19 infection to affirm no COVID-19 related symptoms and contacted facility and completed a facility risk assessment. LPA ensured to apply hand sanitizer before entering the facility and the following Personal Protective Equipment (PPE) was worn surgical mask. LPA was screened upon entry by staff.

The facility submitted a completed Unusual Incident/Injury Report (LIC624) on/around 7/27/2022 regarding resident (R1) leaving the facility unattended on 07/26/22, at approximately 6.00pm. LPA spoke to ED on 07/27/22 and confirmed resident was gone 30-40 minutes after R1 daughter notified facility that her father ‘s location was showing outside the facility from R1 cell phone tracker. ED followed up immediately after the AWOL and found R1 on street next to backside of the facility Resident returned to the facility uninjured. R1 told ED that he jumped from the back-side fence to look for his ex-wife. Facility notified R1 doctor and family on 07/26/22 regarding this AWOL incident.

R1's physician's report, dated 07/10/22, indicates that resident has diagnosis of dementia with behavior disturbance and cannot leave the facility unassisted. This was first AWOL incident for R1 since his admission to the facility. Resident has not tried to leave facility again and has been communicating better with the staff if he needs something.

Per California Code of Regulations, Title 22, Division 6, Chapter 8, 1 deficiency is issued on the 809D page.

Exit interview conducted. Copy of report and appeal rights provided to Executive Director.
SUPERVISOR'S NAME: Laura MunozTELEPHONE: (916) 263-4743
LICENSING EVALUATOR NAME: Talwinder BainsTELEPHONE: (916) 263-4700
LICENSING EVALUATOR SIGNATURE:
DATE: 08/02/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/02/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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Document Has Been Signed on 08/02/2022 10:45 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, 520 COHASSET RD., STE. 170
CHICO, CA 95926


FACILITY NAME: OAKMONT OF WESTPARK
FACILITY NUMBER: 312700863

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/02/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
08/02/2022
Section Cited

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87705- Care of Persons with Dementia (c) Licensees who accept and retain residents with dementia shall be responsible for ensuring the following: (4) There is an adequate number of direct care staff to support each resident’s physical, social, emotional, safety and health care needs as identified in his/her current appraisal. This requirement is not met as evidenced by:
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Based on interviews conducted and record review , the Licensee did not ensure that resident (R1) was unable to leave the facility unassisted, on 7/26/22, which posed an immediate health and safety risk to residents in care.
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LIcensee has also adjusting the fence height after this AWOL incident.

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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: Talwinder BainsTELEPHONE: (916) 263-4700
LICENSING EVALUATOR SIGNATURE:
DATE: 08/02/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/02/2022
LIC809 (FAS) - (06/04)
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