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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 315002798
Report Date: 06/15/2022
Date Signed: 06/15/2022 01:38:24 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
11/23/2021 and conducted by Evaluator Michael Hood
COMPLAINT CONTROL NUMBER: 25-AS-20211123142219
FACILITY NAME:OAKMONT OF ROSEVILLEFACILITY NUMBER:
315002798
ADMINISTRATOR:ERVIN, TERENCEFACILITY TYPE:
740
ADDRESS:1101 SECRET RAVINE PARKWAYTELEPHONE:
(916) 771-6700
CITY:ROSEVILLESTATE: CAZIP CODE:
95661
CAPACITY:120CENSUS: 89DATE:
06/15/2022
UNANNOUNCEDTIME BEGAN:
11:45 AM
MET WITH:Angelique Doyle, Executive DirectorTIME COMPLETED:
01:55 PM
ALLEGATION(S):
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Staff did not prevent a resident from wandering.

Staff do not respond timely to residents' alerts.

Staff do not properly assist residents with oxygen.

Staff are not ensuring the residents have appropriate bedding.
INVESTIGATION FINDINGS:
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On 6/15/2022, Licensing Program Analyst (LPA) Michael Hood arrived at the facility and met with Executive Director (ED), Angelique Doyle, to conclude a complaint investigation into the allegations listed above. LPA wore an N-95 mask and was screened by facility upon entry. Facility staff wore masks while on the premises.

During the investigation, the Department toured the facility, conducted interviews, and reviewed documentation pertinent to the investigation.

The results of the investigation are as follows:

Allegation: Staff did not prevent a resident from wandering

** Report continued on 9099-C **
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Anthony PerezTELEPHONE: (323) 485-4915
LICENSING EVALUATOR NAME: Michael HoodTELEPHONE: 916-531-7341
LICENSING EVALUATOR SIGNATURE:

DATE: 06/15/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/15/2022
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 9
Control Number 25-AS-20211123142219
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 ROSEVILLE
FACILITY NUMBER: 315002798
VISIT DATE: 06/15/2022
NARRATIVE
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According to Unusual Incident Report (LIC 624) submitted to the Department and dated 9/12/2021, on 9/10/2021, resident (R1) was observed to have left the facility unassisted. Facility notified Local Police Department around 9:10 PM. R1 was escorted back to the facility by Local Police at approximately 9:15 PM.

Interview with staff member (S4) indicated that R1 had moved in the Assisted Living Unit (ALU) and was fairly new. The night of the incident, R1 thought the facility was a hotel and wanted to “check out.” R1 initially was in the lobby with no concierge. Staff were checking on R1 every 30 minutes. Staff came around 10 minutes after speaking with R1 and found that R1 was missing.

Interview with ED indicated that Local Police located R1 at Sutter Medical Center (Sutter Medical Center shares parking lot with facility). R1's family was contacted after incident and R1 was moved the same night, 9/10/2021, to the facility's Memory Care Unit (MCU) due to elopement risk.

R1's Physician's Report (LIC 602) dated 8/27/2021 states that R1 is not able to leave the facility unassisted. R1's LIC 602 dated 8/27/2021 also stated that R1 has a primary diagnosis of dementia.

Allegation: Staff do not respond timely to residents' alerts.

Interview with ED indicated that standard response time to residents' call button is 7 minutes, with no more than 15 minutes passing before responding to a resident's call button. LPA reviewed "Questions Related to Alert Pendants at Oakmont," which indicated that "response time is up to 12 minutes, average response time is 4 minutes."

Interviews with staff members S1, S2, S3, S4, S5, and S6 indicated varying times for what would be considered the standard response time to a resident's call button. Interview with S4 indicated that standard response time to residents' call buttons are anywhere between 10 to 15 minutes. Interview with S5 indicated that staff watch pagers and once a call button alert gets "2 tries," staff are alerted to address the call button. The concierge watches a computer in the back and the ED has a pager and can look at response times to monitor staff addressing call buttons. "Try-2" is around 6 minutes. S5 stated that call button alerts may reach "Try-3" if staff need to get from one side of the facility to another. Try-3 is around 10 minutes.

** Report continued on 9099-C **
SUPERVISOR'S NAME: Anthony PerezTELEPHONE: (323) 485-4915
LICENSING EVALUATOR NAME: Michael HoodTELEPHONE: 916-531-7341
LICENSING EVALUATOR SIGNATURE:

DATE: 06/15/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/15/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 9
Control Number 25-AS-20211123142219
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 ROSEVILLE
FACILITY NUMBER: 315002798
VISIT DATE: 06/15/2022
NARRATIVE
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The call button alerts go up to "Try-9." S5 stated that they have only witnessed it get to Try-9 when the call button wasn’t turned off after staff have assisted a resident.

LPA reviewed History of SMARTcare (call button response time records) for 6/3/2022, 6/4/2022, and 6/5/2022. At multiple times on all three days, LPA observed call buttons "announced 9 times" with no time indicated when response was given. At multiple times on all three days, LPA observed call buttons have response times exceeding 15 minutes and reaching as long as 41 minutes.

Allegation: Staff do not properly assist residents with oxygen.

During inspection conducted on 12/2/2021, LPA Sarena Keosavang observed two resident bedrooms (224 & 229) using oxygen that did not have a sign posted on the front door stating that oxygen was in use. Interview with S5 indicated that both residents use oxygen. LPA Keosavang informed S5 that a "No Smoking-Oxygen in Use" sign was not posted on the front of the door of rooms 224 and 229 and that a sign needs to be up. S5 ensured that signs were added to rooms 224 and 229 during visit.

LPA Hood reviewed "Oakmont Management Group: Health Services Policies & Procedures" under "Policy: 219 - Oxygen Safety" which states under procedures that "an 'Oxygen in Use' sign must be posted at the outside entrance to the apartment."

Allegation: Staff are not ensuring the residents have appropriate bedding.

During inspection conducted on 12/2/2021, LPA Keosavang observed room 125. Before entering the bedroom, S5 informed LPA that room smells of urine due to the resident urinating the bed. S5 stated that the facility is waiting for resident's family to change out the bed because that's their responsibility.

Interview with S5 conducted on 6/9/2022 indicated that the facility may supply bedding to residents in the MCU. Families are welcome to provide bedding, but facility encourages residents to use facility bedding since they need to be changed so frequently. S5 stated that the MCU has an abundance of bedding to make sure that bedding is available in all the residents’ rooms.

** Report continued on 9099-C **
SUPERVISOR'S NAME: Anthony PerezTELEPHONE: (323) 485-4915
LICENSING EVALUATOR NAME: Michael HoodTELEPHONE: 916-531-7341
LICENSING EVALUATOR SIGNATURE:

DATE: 06/15/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/15/2022
LIC9099 (FAS) - (06/04)
Page: 3 of 9
Control Number 25-AS-20211123142219
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 ROSEVILLE
FACILITY NUMBER: 315002798
VISIT DATE: 06/15/2022
NARRATIVE
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Interview with ED conducted on 6/14/2022 indicated that facility may ask the family to replace a bed if the whole mattress has been soiled. Facility will dump the soiled mattress and may get a loaner while waiting for the family to replace the mattress. ED stated that a soiled mattress will not sit in a resident’s room for more than one day and is replaced within a 24 to 48 hour period.

Interview with ED indicated that the facility disposed of the mattress in room 125, provided a mattress cover to the residents in room 125 on 3 occasions, communicated to the daughter/Power of Attorney of residents in room 125 regarding the odor due to the incontinence of both residents, and disposed and replaced of a recliner that also smelled of urine in room 125. At this time, the mattress has been replaced. Numerous work orders were completed for carpet cleaning in room 125.

LPA Hood reviewed residents' files for room 125 (R2 and R3). R2's Assessment Form dated 3/4/2021 and 3/24/2022 (prior and after inspection conducted on 12/2/2021) indicated that R2 is "occasionally incontinent of bladder or bowel and can self manage, but requires assistance ordering and maintaining supplies."

Based on interviews conducted by the department, observations, and records reviewed, the preponderance of evidence standards have been met. Therefore, the above allegations are found to be SUBSTANTIATED. Per California Code of Regulations, Title 22 Division 6, Chapter 8, deficiencies are being cited on the attached 9099-D page.

Exit interview was conducted with ED. A copy of this report and appeal rights were provided. The ED’s signature on these forms acknowledges receipt of these documents.
SUPERVISOR'S NAME: Anthony PerezTELEPHONE: (323) 485-4915
LICENSING EVALUATOR NAME: Michael HoodTELEPHONE: 916-531-7341
LICENSING EVALUATOR SIGNATURE:

DATE: 06/15/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/15/2022
LIC9099 (FAS) - (06/04)
Page: 4 of 9
Control Number 25-AS-20211123142219
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 ROSEVILLE
FACILITY NUMBER: 315002798
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/15/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
06/16/2022
Section Cited
CCR
87705(c)(4)
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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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ED incorporated a wanderguard system at the facility after incident. All residents in the ALU have call buttons at all times. R1 was moved to MCU the same day of incident. ED will conduct a training regarding AWOLs on 6/29/2022 at 2:00 PM. ED will provide training materials to department by POC due date.
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Based on interviews conducted and records reviewed, the facility did not ensure that R1 was properly supervised, resulting in R1’s AWOL, which poses an immediate health, safety, and personal rights risk to residents in care.
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Type B
06/30/2022
Section Cited
CCR
87411(a)
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87411 Personnel Requirements - General (a) Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs. This requirement is not met as evidenced by:
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ED has ensured that call button system is correctly operating to ensure accurate response times. ED will conduct a training regarding proper call button clearance and response time management on 6/29/2022. ED will provide training materials to department by POC due date.
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Based on records reviewed, the facility did not ensure call buttons for residents were responded to in a timely manner, resulting in response times reaching 41 minutes, which poses a potential health, safety, and personal rights 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: Anthony PerezTELEPHONE: (323) 485-4915
LICENSING EVALUATOR NAME: Michael HoodTELEPHONE: 916-531-7341
LICENSING EVALUATOR SIGNATURE:

DATE: 06/15/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/15/2022
LIC9099 (FAS) - (06/04)
Page: 5 of 9
Control Number 25-AS-20211123142219
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 ROSEVILLE
FACILITY NUMBER: 315002798
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/15/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
07/07/2022
Section Cited
CCR
87618(b)(3)(B)
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87618 Oxygen Administration - Gas and Liquid (b) In addition to Section 87611(b), the licensee shall be responsible for the following: (3) Ensuring that the use of oxygen equipment meets the following requirements: (B) "No Smoking-Oxygen in Use" signs shall be posted in the appropriate areas. This requirement is not met as evidenced by:
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ED ensured that all apartments with residents using oxygen have "No Smoking-Oxygen in Use" signs on doors. ED will complete a statement of understanding regarding regulation 87618 and submit to department by POC due date.
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Based on observations, the facility did not ensure that "No Smoking-Oxygen in Use" signs were posted on every apartment door with a resident using oxygen, which poses a potential health, safety, and personal rights risk to residents in care.
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Request Denied
Type B
07/07/2022
Section Cited
CCR
87307(a)(3)(A)
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87307 Personal Accommodations and Services (a) Living accommodations and grounds shall be related to the facility's function. (...) The following provisions shall apply: (3) Equipment and supplies necessary for personal care and maintenance of adequate hygiene practice shall be readily available to each resident. (...) (A) (...) Each bed shall be equipped with good springs, a clean and comfortable mattress, available pillow(s) and lightweight warm bedding. This requirement is not met as evidenced by:
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ED indicated that the facility disposed of the mattress in room 125 and communicated to the daughter/Power of Attorney of residents in room 125 regarding the odor due to the incontinence of both residents. At this time, the mattress has been replaced. Numerous work orders were completed for carpet cleaning in room 125.
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Based on observations and interview conducted, the facility did not ensure that R2's bedroom had a clean and comfortable mattress during 12/2/2021 inspection, which poses a potential health, safety, and personal rights risk to residents in care.
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ED will complete a statement of understanding regarding regulation 87307 and submit to department by POC due date.
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: Anthony PerezTELEPHONE: (323) 485-4915
LICENSING EVALUATOR NAME: Michael HoodTELEPHONE: 916-531-7341
LICENSING EVALUATOR SIGNATURE:

DATE: 06/15/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/15/2022
LIC9099 (FAS) - (06/04)
Page: 6 of 9
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
11/23/2021 and conducted by Evaluator Michael Hood
COMPLAINT CONTROL NUMBER: 25-AS-20211123142219

FACILITY NAME:OAKMONT OF ROSEVILLEFACILITY NUMBER:
315002798
ADMINISTRATOR:ERVIN, TERENCEFACILITY TYPE:
740
ADDRESS:1101 SECRET RAVINE PARKWAYTELEPHONE:
(916) 771-6700
CITY:ROSEVILLESTATE: CAZIP CODE:
95661
CAPACITY:120CENSUS: 89DATE:
06/15/2022
UNANNOUNCEDTIME BEGAN:
11:45 AM
MET WITH:Angelique Doyle, Executive DirectorTIME COMPLETED:
01:55 PM
ALLEGATION(S):
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Staff make inappropriate comments towards the residents.

Staff do not ensure the residents are properly fed while in care.

Staff do not properly maintain the facility.

Facility does not have the appropriate amount of staff.

Staff do not protect the residents personal information.
INVESTIGATION FINDINGS:
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On 6/15/2022, Licensing Program Analyst (LPA) Michael Hood arrived at the facility and met with Executive Director (ED), Angelique Doyle, to conclude a complaint investigation into the allegations listed above. LPA wore an N-95 mask and was screened by facility upon entry. Facility staff wore masks while on the premises.

During the investigation, the Department toured the facility, conducted interviews, and reviewed documentation pertinent to the investigation.

The results of the investigation are as follows:

Allegation: Staff make inappropriate comments towards the residents

** Report continued on 9099-C **
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Anthony PerezTELEPHONE: (323) 485-4915
LICENSING EVALUATOR NAME: Michael HoodTELEPHONE: 916-531-7341
LICENSING EVALUATOR SIGNATURE:

DATE: 06/15/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/15/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 7 of 9
Control Number 25-AS-20211123142219
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 ROSEVILLE
FACILITY NUMBER: 315002798
VISIT DATE: 06/15/2022
NARRATIVE
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Interviews with staff members S1, S2, S3, S4, S5, S6, and residents R4, R5, R6, and R7 indicated that no staff have ever been witnessed making inappropriate comments towards residents in care.

Allegation: Staff do not ensure the residents are properly fed while in care

Interview with staff member S7 indicated that dietary restrictions are sent to kitchen from Medical Technicians based on doctor’s orders. Dietary restrictions are posted in the kitchen. Kitchen staff prepare food according to dietary restrictions. Servers know the dietary restrictions of the residents they are serving as well.

LPA observed posted dietary restrictions in kitchen during inspection conducted on 6/14/2022.

Interviews with staff members S4, S5, and S6 indicated that residents who need assistance with feeding (all of which are in the Memory Care Unit [MCU]) are provided services in the dining room by care staff.

Interview with residents R4, R5, R6, and R7 indicated that they have options when selecting meals. LPA obtained a copy of the facility's menu for the month of November 2021, as well as 6/13/22 and 6/14/2022, and observed multiple food options for residents.

Allegation: Staff do not properly maintain the facility

During inspection conducted on 12/2/21, LPA Sarena Keosavang observed a random resident's bedroom to be clean and odorless.

Interviews with staff members S1, S2, S3, S4, S5, S6, and residents R4, R5, R6, and R7 indicated that they have never witnessed the facility to be unsanitary or in disrepair.

Allegation: Facility does not have the appropriate amount of staff

** Report continued on 9099-C **
SUPERVISOR'S NAME: Anthony PerezTELEPHONE: (323) 485-4915
LICENSING EVALUATOR NAME: Michael HoodTELEPHONE: 916-531-7341
LICENSING EVALUATOR SIGNATURE:

DATE: 06/15/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/15/2022
LIC9099 (FAS) - (06/04)
Page: 8 of 9
Control Number 25-AS-20211123142219
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 ROSEVILLE
FACILITY NUMBER: 315002798
VISIT DATE: 06/15/2022
NARRATIVE
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Interviews with staff members S4, S5, and S6 indicated that the facility is utilizing a registry to address shortages in staffing. Interviews with residents R4, R5, R6, and R7 indicated that the facility has sufficient staff. R4, R5, R6, and R7 have no complaints regarding the amount of staff at the facility.

Allegation: Staff do not protect the residents personal information

Interviews with Staff Members S1, S2, S3, S4, S5, S6, and ED indicated that no resident names are ever used on portable radios and residents are identified by room number. Interviews with residents R4, R6, and R7 indicated that they have never been able to identify what resident is being addressed on a portable radio. Interview with S4 and ED indicated that staff avoid discussing residents in common areas of the building regardless if the discussion involves personal information pertaining to a resident.

Based on interviews conducted by the Department, observation, and records reviewed, the preponderance of evidence standards have not been met. Therefore, the above allegations are found to be UNSUBSTANTIATED. A finding that a complaint allegation is unsubstantiated means that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred.

Exit interview was conducted with ED and a copy of this report was provided to the facility. The signature of the ED on these forms acknowledges receipt of these documents.
SUPERVISOR'S NAME: Anthony PerezTELEPHONE: (323) 485-4915
LICENSING EVALUATOR NAME: Michael HoodTELEPHONE: 916-531-7341
LICENSING EVALUATOR SIGNATURE:

DATE: 06/15/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/15/2022
LIC9099 (FAS) - (06/04)
Page: 9 of 9