312700863-11-8-2021-25-AS-KHOS-C9JNME-20211209093500

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 312700863
Report Date: 11/08/2021
Date Signed: 11/08/2021 02:46:04 PM

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
06/29/2021 and conducted by Evaluator Kerry Hiratsuka

COMPLAINT CONTROL NUMBER: 25-AS-20210629090404

FACILITY NAME:	OAKMONT OF WESTPARK		FACILITY NUMBER:	312700863
ADMINISTRATOR:	FERNANDEZ, TAMARA		FACILITY TYPE:	740
ADDRESS:	2400 PLEASANT GROVE BLVD		TELEPHONE:	(916) 789-2000
CITY:	ROSEVILLE	STATE: CA	ZIP CODE:	95747
CAPACITY:	142	CENSUS: 73	DATE:	11/08/2021
		UNANNOUNCED	TIME BEGAN:	01:00 PM
MET WITH:	RubyRamirez, Regional Health Services Specialist; Kayleigh Daniles, Traditions Director		TIME COMPLETED:	02:55 PM

ALLEGATION(S):

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Facility did not respond to changes in resident’s condition.

INVESTIGATION FINDINGS:

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Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Troy Ordonez	TELEPHONE: (916) 263-4832
LICENSING EVALUATOR NAME: Kerry Hiratsuka	TELEPHONE: (916) 591-0210
LICENSING EVALUATOR SIGNATURE:	DATE: 11/08/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/08/2021

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

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
06/29/2021 and conducted by Evaluator Kerry Hiratsuka

COMPLAINT CONTROL NUMBER: 25-AS-20210629090404

FACILITY NAME:	OAKMONT OF WESTPARK		FACILITY NUMBER:	312700863
ADMINISTRATOR:	FERNANDEZ, TAMARA		FACILITY TYPE:	740
ADDRESS:	2400 PLEASANT GROVE BLVD		TELEPHONE:	(916) 789-2000
CITY:	ROSEVILLE	STATE: CA	ZIP CODE:	95747
CAPACITY:	142	CENSUS: 73	DATE:	11/08/2021
		UNANNOUNCED	TIME BEGAN:	01:00 PM
MET WITH:	RubyRamirez, Regional Health Services Specialist; Kayleigh Daniles, Traditions Director		TIME COMPLETED:	02:55 PM

ALLEGATION(S):

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1. Resident sustained injuries while in care.
2. Resident sustained multiple falls while in care.
3. Facility does not have adequate supervision.
4. Staff are not adequately trained to transfer resident.
5. Facility did not provide activities for residents.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Kerry Hiratsuka arrived unannounced to deliver findings into the allegations above. LPA met with RubyRamirez, Regional Health Services Specialist; Kayleigh Daniles, Traditions Director during today’s visit. LPA completed required COVID-19 testing protocols, and a daily self-screening questionnaire for symptoms of COVID-19 infection to affirm no COVID-19 related symptoms. LPA ensured they applied hand sanitizer before entering the facility and the following Personal Protective Equipment (PPE) was worn: N-95 Masks. Additionally, LPA was screened by staff upon entering the facility.
1. LPA investigation the allegation “Resident sustained injuries while in care..” LPA interviewed facility staff and reviewed facility documentation. LPA also reviewed Complainant's documentation. LPA was unable to interview the former resident. LPA unable to interview caregivers who worked at facility during this time.
Per the dischage summary paperwork from the hospital after two stays, only one mentioned fall prevention, but did not note any injures. The second discharge summary paperwork from the hospital did not mention any injury but had handwritten notes from the doctor about clenaing the scrotom, but does not mention why that is there. There are no other notes in the facility paperwork regarding other falls. This occured in June 2021. LPA cannot prove or disprove either version of events. Allegation is unsubstantiated.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Troy Ordonez	TELEPHONE: (916) 263-4832
LICENSING EVALUATOR NAME: Kerry Hiratsuka	TELEPHONE: (916) 591-0210
LICENSING EVALUATOR SIGNATURE:	DATE: 11/08/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/08/2021

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 5

Control Number 25-AS-20210629090404

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: 11/08/2021

NARRATIVE

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2. LPA investigation the allegation “Resident sustained multiple falls while in care. ..” LPA interviewed facility staff and reviewed facility documentation. LPA also reviewed Complainant's documentation. LPA was unable to interview the former resident. LPA unable to interview caregivers who worked at facility during this time. Facility has a standard fall prevention plan for residents in care and the written individual service plane mentioned they were going to use it. Title 22 regulations does require a written plan of care for each resident, but it does not specify how specific each plan has to be. Per facility documentation there were only two falls noted and one mentioned a family member was a part of one of the falls. LPA cannot prove or disprove each side of events on the number of falls the resident had as well as the reasons behind each fall.. Allegation is unsubstantiated.

3. LPA investigation the allegation “Facility does not have adequate supervision..” LPA interviewed facility staff and reviewed facility documentation. LPA also reviewed Complainant's documentation. LPA was unable to interview the former resident. LPA unable to interview caregivers who worked at facility during this time. Title 22 regulations does not require a caregiver to be with a resident every minute of each day. There was a resident who did go into the former resident's room one time and the room required a thorough cleaning after. This incident occurred in the memory care area of the building. What cannot be determined is if the resident required more supervision or not. LPA cannot prove or disprove if the facility had adequate supervision at the time of the event. Allegation is unsubstantiated.

4. LPA investigation the allegation “Staff are not adequately trained to transfer resident.” LPA interviewed facility staff and reviewed facility documentation. LPA also reviewed Complainant's documentation. LPA was unable to interview the former resident. LPA unable to interview caregivers who worked at facility during this time. LPA obtained training records from the facility regarding lifts and transfers. There was one transfer mentioned in the facility notes that a family member was involved with a transfer with the former resident that required five people to assist with the transfer. LPA cannot prove or disprove that staff were not adequately trained based on the above.

5. LPA investigation the allegation “Facility did not provide activities for residents.” LPA interviewed facility staff and reviewed facility documentation. LPA also reviewed Complainant's documentation. LPA was unable to interview the former resident. LPA unable to interview caregivers who worked at facility during this time. LPA cannot prove or disprove if activities were offered to the resident during the time of stay. Allegation is unsubstantiated.

SUPERVISOR'S NAME: Troy Ordonez	TELEPHONE: (916) 263-4832
LICENSING EVALUATOR NAME: Kerry Hiratsuka	TELEPHONE: (916) 591-0210
LICENSING EVALUATOR SIGNATURE:	DATE: 11/08/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/08/2021

LIC9099 (FAS) - (06/04)

Page: 5 of 5

Control Number 25-AS-20210629090404

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: 11/08/2021

NARRATIVE

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LPA was unable to interview caregivers who worked during the short time the resident was at this facility because this occurred in June 2021, and all the caregivers have since changed. Based on interviews Traditions Director, and the Health Services Director on 10/06/2021, the resident was a two-person assist and required a hoyer lift. There was an email from the doctor that mentioned the resident might need a hoyer lift to stand. A review of the facility individual service plan, it did not mention a hoyer lift and it said the resident was a one-person assist. Based on the interviews, the allegation is substantiated because even though the facility was most likely doing a two-person assist and using a hoyer lift, it was not updated in the individual service plan.

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 Ordonez	TELEPHONE: (916) 263-4832
LICENSING EVALUATOR NAME: Kerry Hiratsuka	TELEPHONE: (916) 591-0210
LICENSING EVALUATOR SIGNATURE:	DATE: 11/08/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/08/2021

LIC9099 (FAS) - (06/04)

Page: 2 of 5

Control Number 25-AS-20210629090404

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: 11/08/2021

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 12/08/2021 Section Cited CCR 87463(c)	1 2 3 4 5 6 7	Reappraisals. The licensee shall arrange a meeting with the resident, the resident’s representative, if any, appropriate facility staff, and a representative of the resident’s home health agency, if any, when there is significant change in the resident’s condition, or once every 12 months, whichever occurs first,	1 2 3 4 5 6 7	By 12/08/2021, LIcensee shall submit a written plan of correction on how they are going to ensure when there is a resident's change of condition, how and when it will be documented in a resident's file.
	8 9 10 11 12 13 14	Licensee failed this by not updating the individual service plan for the resident from requiring one-person assist to tw-person assist and also the requiring a hoyer lift. The facility staff were doing the above, but it wasn't written down. This is a possible health and safety risk to residents.	8 9 10 11 12 13 14
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

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 Ordonez	TELEPHONE: (916) 263-4832
LICENSING EVALUATOR NAME: Kerry Hiratsuka	TELEPHONE: (916) 591-0210
LICENSING EVALUATOR SIGNATURE:	DATE: 11/08/2021

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/08/2021

LIC9099 (FAS) - (06/04)

Page: 3 of 5