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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 312700863
Report Date: 04/18/2023
Date Signed: 04/18/2023 01:31:51 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 2525 NATOMAS PARK DR STE 270
SACRAMENTO, CA 95833
This is an official report of an unannounced visit/investigation of a complaint received in our office on
01/04/2023 and conducted by Evaluator Bethany Mirlohi
COMPLAINT CONTROL NUMBER: 25-AS-20230104170150
FACILITY NAME:OAKMONT OF WESTPARKFACILITY NUMBER:
312700863
ADMINISTRATOR:JESSICA PRYORFACILITY TYPE:
740
ADDRESS:2400 PLEASANT GROVE BLVDTELEPHONE:
(916) 789-2000
CITY:ROSEVILLESTATE: CAZIP CODE:
95747
CAPACITY:0CENSUS: 0DATE:
04/18/2023
UNANNOUNCEDTIME BEGAN:
11:15 AM
MET WITH:William P. Gallaher, Chief Executive OfficerTIME COMPLETED:
11:30 AM
ALLEGATION(S):
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Lack of care and supervision: resident assaulted another resident resulting in hospitalization.
Resident barricaded facility door.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Bethany Mirlohi is delivering complaint findings concerning allegations listed above.
The department investigated allegation, “Lack of care and supervision: resident assaulted another resident resulting in hospitalization”. The department interviewed staff, relevant parties and reviewed facility documentation. On 11/03/22, R1 moved into the facility to a shared room in the memory care unit with R2. Documentation evidence was obtained from the facility showing that staff were aware that R2 had a substantial history of barricading himself in his room, using furniture to block the exit and bathroom door of his room, prior to the deciding being made to move R1 into his room.

Continuation on 9099-C.
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Troy OrdonezTELEPHONE: (916) 263-4832
LICENSING EVALUATOR NAME: Bethany MirlohiTELEPHONE: (916) 204-8288
LICENSING EVALUATOR SIGNATURE:

DATE: 04/18/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/18/2023
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 25-AS-20230104170150
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 2525 NATOMAS PARK DR STE 270
SACRAMENTO, CA 95833
FACILITY NAME: OAKMONT OF WESTPARK
FACILITY NUMBER: 312700863
VISIT DATE: 04/18/2023
NARRATIVE
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Multiple staff were interviewed and confirmed that R2 barricaded regularly, presenting a danger to himself and any potential roommate. An interview with a staff member indicated that R2 would sometimes remain barricaded for the entire overnight shift and that staff were unable to gain entry to R2’s room to conduct an “eyes on” check through the door. Interviews were supported by documentation obtained in the form of “care notes: that R2’s door was unable to be opened throughout the night on multiple occasions. On the night of 11/4/22-11/5/22, R1 fell on and was assaulted by R2, after R2 had blocked the bathroom door with his mattress. R1 was then sent to the emergency room and skin tears were observed on R1’s wrist and right elbow. R1 was diagnosed with an injury due to assault, multiple skin tears, and a contusion. Due to the information gathered the department finds allegation to be substantiated.
The department investigated allegation, “Resident barricaded facility door.” The department interviewed staff, relevant parties, and reviewed facility documentation. Documentation evidence was obtained from the facility showing that staff were aware that R2 had a substantial history of barricading himself in his room, using furniture to block the exit and bathroom door of his room, prior to the deciding being made to move R1 into his room. Multiple staff were interviewed and confirmed that R2 barricaded regularly, presenting a danger to himself and any potential roommate. An interview with a staff member indicated that R2 would sometimes remain barricaded for the entire overnight shift and that staff were unable to gain entry to R2’s room to conduct an “eyes on” check through the door. Interviews were supported by documentation obtained in the form of “care notes: that R2’s door was unable to be opened throughout the night on multiple occasions.
Continuation on 9099-C.
SUPERVISOR'S NAME: Troy OrdonezTELEPHONE: (916) 263-4832
LICENSING EVALUATOR NAME: Bethany MirlohiTELEPHONE: (916) 204-8288
LICENSING EVALUATOR SIGNATURE:

DATE: 04/18/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/18/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 6
Control Number 25-AS-20230104170150
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 2525 NATOMAS PARK DR STE 270
SACRAMENTO, CA 95833

FACILITY NAME: OAKMONT OF WESTPARK
FACILITY NUMBER: 312700863
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/18/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
04/18/2023
Section Cited
CCR
87468.1(a)(2)
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87468.1 Personal Rights of Residents in All Facilities (a)Residents in all residential care facilities for the elderly shall have all of the following personal rights: (2) To be accorded safe, healthful and comfortable accommodations, furnishings and equipment.
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No plan of correction due to facility no longer being licensed.
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This requirement is not met as evidenced by: Based on interviews and record reviews the licensee did not provide safe, healthful, and comfortable accommodations for R1 which posed an immediate health and safety risk to residents in care.
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Type A
04/18/2023
Section Cited
CCR
87466
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87466 Observation of the Resident. The licensee shall ensure that residents are regularly observed for changes in physical, mental, emotional and social functioning and that appropriate assistance is provided when such observation reveals unmet needs. When changes such as unusual weight gains or losses or deterioration of mental ability or a physical health condition are observed, the licensee shall ensure that such changes are documented and brought to the attention of the resident's physician and the resident's responsible person, if any.
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No plan of correction due to facility no longer being licensed.
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This requirement is not met as evidenced by: Based on interviews and record reviews the licensee did not support for R2's behaviors which posed an immediate health and safety risk to residents in care.
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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: Bethany MirlohiTELEPHONE: (916) 204-8288
LICENSING EVALUATOR SIGNATURE:

DATE: 04/18/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/18/2023
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
SACRAMENTO NORTH ASC, 2525 NATOMAS PARK DR STE 270
SACRAMENTO, CA 95833
This is an official report of an unannounced visit/investigation of a complaint received in our office on
01/04/2023 and conducted by Evaluator Bethany Mirlohi
COMPLAINT CONTROL NUMBER: 25-AS-20230104170150

FACILITY NAME:OAKMONT OF WESTPARKFACILITY NUMBER:
312700863
ADMINISTRATOR:JESSICA PRYORFACILITY TYPE:
740
ADDRESS:2400 PLEASANT GROVE BLVDTELEPHONE:
(916) 789-2000
CITY:ROSEVILLESTATE: CAZIP CODE:
95747
CAPACITY:0CENSUS: 0DATE:
04/18/2023
UNANNOUNCEDTIME BEGAN:
11:15 AM
MET WITH:William P. Gallaher, Chief Executive OfficerTIME COMPLETED:
11:30 AM
ALLEGATION(S):
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Resident suffered multiple falls while in care.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Bethany Mirlohi is delivering complaint findings concerning allegations listed above.
The department investigated allegation, “Resident suffered multiple falls while in care.” The department interviewed staff, relevant parties, and reviewed facility documentation. Interviews with relevant party indicate that R1 had a fall on 11/20/22 in the dining room. On 12/26/22 resident had a fall and obtained skin tears. The following day resident was sent to the hospital due to suspicious of a stroke or seizure. LPA interviewed caregivers in which they stated they were unaware of any falls that R1 had. LPA reviewed facility documentation and did not observe a fall that took place. Due to the information gathered LPA was unable to determine if resident had multiple falls and injuries that occurred due to the falls.
Continuation on 9099-C.
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Troy OrdonezTELEPHONE: (916) 263-4832
LICENSING EVALUATOR NAME: Bethany MirlohiTELEPHONE: (916) 204-8288
LICENSING EVALUATOR SIGNATURE:

DATE: 04/18/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/18/2023
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-20230104170150
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 2525 NATOMAS PARK DR STE 270
SACRAMENTO, CA 95833
FACILITY NAME: OAKMONT OF WESTPARK
FACILITY NUMBER: 312700863
VISIT DATE: 04/18/2023
NARRATIVE
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LPA finds allegation to be UNSUBSTANTIATED. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove that the alleged violations occurred, and the findings are unsubstantiated.

LPA will mail a copy of report to licensee. Licensee to review, sign, and return a signed report to CCL my mail or email. Please direct all correspondence regarding this complaint to the attention of Bethany Mirlohi at the Departments Regional Office:

2525 Natomas Park Drive., Suite 270
Sacramento, CA 95833
Bethany.mirlohi@dss.ca.gov.
SUPERVISOR'S NAME: Troy OrdonezTELEPHONE: (916) 263-4832
LICENSING EVALUATOR NAME: Bethany MirlohiTELEPHONE: (916) 204-8288
LICENSING EVALUATOR SIGNATURE:

DATE: 04/18/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/18/2023
LIC9099 (FAS) - (06/04)
Page: 5 of 6
Control Number 25-AS-20230104170150
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 2525 NATOMAS PARK DR STE 270
SACRAMENTO, CA 95833
FACILITY NAME: OAKMONT OF WESTPARK
FACILITY NUMBER: 312700863
VISIT DATE: 04/18/2023
NARRATIVE
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Due to the information gathered the department finds allegation to be substantiated. As a result of this investigation, LPA finds allegations to be (S) Substantiated - A finding that the complaint is Substantiated means that the allegation is valid because the preponderance of the evidence standard has been met. Deficiencies cited on 9099-D.
LPA will mail a copy of report to licensee. Licensee to review, sign, and return a signed report to CCL my mail or email. Please direct all correspondence regarding this complaint to the attention of Bethany Mirlohi at the Departments Regional Office:

2525 Natomas Park Drive., Suite 270
Sacramento, CA 95833
Bethany.mirlohi@dss.ca.gov.
SUPERVISOR'S NAME: Troy OrdonezTELEPHONE: (916) 263-4832
LICENSING EVALUATOR NAME: Bethany MirlohiTELEPHONE: (916) 204-8288
LICENSING EVALUATOR SIGNATURE:

DATE: 04/18/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/18/2023
LIC9099 (FAS) - (06/04)
Page: 6 of 6