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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 312700863
Report Date: 04/14/2022
Date Signed: 05/20/2022 01:53:19 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, 520 COHASSET RD., STE. 170
CHICO, CA 95926
This is an official report of an unannounced visit/investigation of a complaint received in our office on
01/25/2022 and conducted by Evaluator Kerry Hiratsuka
COMPLAINT CONTROL NUMBER: 25-AS-20220125154747
FACILITY NAME:OAKMONT OF WESTPARKFACILITY NUMBER:
312700863
ADMINISTRATOR:CASSIANA BUSHFACILITY TYPE:
740
ADDRESS:2400 PLEASANT GROVE BLVDTELEPHONE:
(916) 789-2000
CITY:ROSEVILLESTATE: CAZIP CODE:
95747
CAPACITY:142CENSUS: DATE:
04/14/2022
UNANNOUNCEDTIME BEGAN:
12:34 PM
MET WITH:Antonette Edwards, Executive DirectorTIME COMPLETED:
03:45 PM
ALLEGATION(S):
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Staff are not meeting resident's hygiene needs
Resident's room is dirty
Staff are not changing resident's bedding
Staff are not providing resident's with adequate laundry services
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Kerry Hiratsuka, arrived at the facility unannounced on 04/14/2022, to conduct a Complaint Investigation Visit. LPA conducted COVID-19 Precautionary prescreening, and wore a surgical mask while at facility. LPA was screened by Front Desk.

LPA investigated the allegation “Staff are not meeting resident's hygiene needs; Resident's room is dirty
Staff are not changing resident's bedding ; Staff are not providing resident's with adequate laundry services.” LPA interviewed facility staff and reviewed facility documentation. LPA also reviewed Complainant's documentation and attempted to interview resident. Resident was unable to be interviewed due to mental condition.


amendend report delived on 05/20/2022, due to adding on one more citation for not meeting hygeine needs.
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Troy OrdonezTELEPHONE: (916) 263-4832
LICENSING EVALUATOR NAME: Kerry HiratsukaTELEPHONE: (916) 591-0210
LICENSING EVALUATOR SIGNATURE:

DATE: 04/14/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/14/2022
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
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 520 COHASSET RD., STE. 170
CHICO, CA 95926
This is an official report of an unannounced visit/investigation of a complaint received in our office on
01/25/2022 and conducted by Evaluator Kerry Hiratsuka
COMPLAINT CONTROL NUMBER: 25-AS-20220125154747

FACILITY NAME:OAKMONT OF WESTPARKFACILITY NUMBER:
312700863
ADMINISTRATOR:CASSIANA BUSHFACILITY TYPE:
740
ADDRESS:2400 PLEASANT GROVE BLVDTELEPHONE:
(916) 789-2000
CITY:ROSEVILLESTATE: CAZIP CODE:
95747
CAPACITY:142CENSUS: DATE:
04/14/2022
UNANNOUNCEDTIME BEGAN:
12:34 PM
MET WITH:Antonette Edwards, Executive DirectorTIME COMPLETED:
03:45 PM
ALLEGATION(S):
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1. Staff did not safeguard resident's personal belongings
2. Not enough staff to supervise residents
3. Facility not reporting incidents to CCLD
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Kerry Hiratsuka, arrived at the facility unannounced on 04/14/2022, to conduct a Complaint Investigation Visit. LPA conducted COVID-19 Precautionary prescreening, and wore a surgical mask while at facility. LPA was screened by Front Desk.

LPA investigated the allegation “1. Staff did not safeguard resident's personal belongings; 2.Not enough staff to supervise residents; 3. Facility not reporting incidents to CCLD.” LPA interviewed facility staff and reviewed facility documentation. LPA also reviewed Complainant's documentation and attempted to interview resident. Resident was unable to be interviewed due to mental condition.
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Troy OrdonezTELEPHONE: (916) 263-4832
LICENSING EVALUATOR NAME: Kerry HiratsukaTELEPHONE: (916) 591-0210
LICENSING EVALUATOR SIGNATURE:

DATE: 04/14/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/14/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 4 of 6
Control Number 25-AS-20220125154747
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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
VISIT DATE: 04/14/2022
NARRATIVE
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1. The allegation is regarding the memory care unit. The apartment rooms are not locked to prevent residents from getting in unless requested by the responsible party and resident. Residents do wander into other resident rooms from time to time. Residents also misplace items of their own and cannot remember where they put them. The facility does discourage valuables from being brought into the facility because of these reasons. Staff also try to redirect residents when they see them entering other people's rooms. Staff do try to return things back to people as they find them. This allegation deals with clothes of the residents. All clothes are required to have their names on them. LPA was informed that the clothes are laundered by resident specific and not lumped together and washed at the same time and from there staff are to put the clothes into the resident rooms. Residents have misplaced their clothes from time to time. Based on the above, the allegation cannot be proved or disproved. Allegation unsubstantiated.

2. A resident did make it out of the memory care unit, but did not make it out of the building. The resident pressed on the delayed egress doors until it opened. A staff person just outside the memory care unit found the resident and walked with the resident until the resident was ready to go back into the memory care section. LPA cannot prove or disprove if the resident was able to open the doors due to lack of staff. Allegation unsubstantiated.

3. There are certain incidents that are required to be reported to Community Care Licensing Division(CCLD) per Title 22 regulations. The incident in question is the one about a resident making it out of the memory care unit. LPA was told a resident did make it out of the delayed egress doors by pressing on it till it opened but there was a staff person just outside the doors that stopped the resident and walked the resident around the assisted living side of the building for a short time and then brought back after the walk. This situation was not reported to CCLD, but it is difficult to determine if it meets the threshold of being required to be reported because the resident did not leave the building and LPA is unable to determine if there is more that occurred. Based on the above, the allegation is unsubstantiated.
SUPERVISOR'S NAME: Troy OrdonezTELEPHONE: (916) 263-4832
LICENSING EVALUATOR NAME: Kerry HiratsukaTELEPHONE: (916) 591-0210
LICENSING EVALUATOR SIGNATURE:

DATE: 04/14/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/14/2022
LIC9099 (FAS) - (06/04)
Page: 5 of 6
Control Number 25-AS-20220125154747
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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
VISIT DATE: 04/14/2022
NARRATIVE
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The incidents occurred the beginning of to the middle of January 2022. LPA was given pictures of the dirty room, laundry, and bedding. The soiled laundry and bedding were not removed as soon as possible to be laundered at that time. LPA was informed there were some issues monitoring the resident's hygiene and it has all since been addressed and changes are still being made to ensure the resident's hygiene and cleanliness of the room.

Based on the interviews and facility file regarding the former resident the allegation is substantiated. Deficiencies cited from Title 22 Regulations and or the California Health and Safety Code. Failure to correct shall result in civil penalties.
SUPERVISOR'S NAME: Troy OrdonezTELEPHONE: (916) 263-4832
LICENSING EVALUATOR NAME: Kerry HiratsukaTELEPHONE: (916) 591-0210
LICENSING EVALUATOR SIGNATURE:

DATE: 04/14/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/14/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 6
Control Number 25-AS-20220125154747
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 04/14/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
04/15/2022
Section Cited
CCR
87468.1(a)(2)
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Personal Rights of Residents in All Facilities. Residents in all residential care facilities for the elderly shall have all of the following personal rights: To be accorded safe, healthful and comfortable accommodations, furnishings and equipment.
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***this has been cleared. The issues have been addressed through a meeting with the responsible party***
Executive Director stated she will also submit in writing a plan on how to address issues brought to the company's concern.
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This requirement was not met as evidenced by pictures that were submitted of the dirty room, soiled clothes, and bedding. This is an immediate risk to the resident.
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Request Denied
Type A
05/20/2022
Section Cited
CCR
87464(f)(4)
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Basic Services. Basic services shall at a minimum include: Personal assistance and care as needed by the resident and as indicated in the pre-admission appraisal, with those activities of daily living such as dressing, eating, bathing and assistance with taking prescribed medications, as
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***this has been cleared because the faciltiy had a meeting with the responsible party and the resident was reassessed and the care plan was adjusted***.
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specified in Section 87608, Postural Supports
This requirement was not met as evidenced by pictures and interviews stating the resident would soil themselves and be left in dirty clothing due to not being properly assesed by the facility.
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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: Troy OrdonezTELEPHONE: (916) 263-4832
LICENSING EVALUATOR NAME: Kerry HiratsukaTELEPHONE: (916) 591-0210
LICENSING EVALUATOR SIGNATURE:

DATE: 04/14/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/14/2022
LIC9099 (FAS) - (06/04)
Page: 3 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, 520 COHASSET RD., STE. 170
CHICO, CA 95926
This is an official report of an unannounced visit/investigation of a complaint received in our office on
01/25/2022 and conducted by Evaluator Kerry Hiratsuka
COMPLAINT CONTROL NUMBER: 25-AS-20220125154747

FACILITY NAME:OAKMONT OF WESTPARKFACILITY NUMBER:
312700863
ADMINISTRATOR:CASSIANA BUSHFACILITY TYPE:
740
ADDRESS:2400 PLEASANT GROVE BLVDTELEPHONE:
(916) 789-2000
CITY:ROSEVILLESTATE: CAZIP CODE:
95747
CAPACITY:142CENSUS: DATE:
04/14/2022
UNANNOUNCEDTIME BEGAN:
12:34 PM
MET WITH:Antonette Edwards, Executive DirectorTIME COMPLETED:
03:45 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Facility has no actitivies
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Licensing Program Analyst (LPA) Kerry Hiratsuka, arrived at the facility unannounced on 04/14/2022, to conduct a Complaint Investigation Visit. LPA conducted COVID-19 Precautionary prescreening, and wore a surgical mask while at facility. LPA was screened by Front Desk.
LPA investigated the allegation “Facility has no actitivies.” LPA interviewed facility staff and reviewed facility documentation. LPA also reviewed Complainant's documentation and attempted to interview resident. Resident was unable to be interviewed due to mental condition.
This allegation regards the memory care unit. LPA observed activities in each of the previous visits that LPA did. The facility also has a schedule for activities. Activities are stopped if there is an infectious disease outbreak.
“This agency has investigated the complaint alleging; Facility has no actitivies. We have found that the complaint was unfounded, meaning that the allegation was false, could not have happened and/or is without a reasonable basis."
Unfounded
Estimated Days of Completion:
SUPERVISOR'S NAME: Troy OrdonezTELEPHONE: (916) 263-4832
LICENSING EVALUATOR NAME: Kerry HiratsukaTELEPHONE: (916) 591-0210
LICENSING EVALUATOR SIGNATURE:

DATE: 04/14/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/14/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 6 of 6