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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 315002955
Report Date: 06/07/2023
Date Signed: 06/07/2023 03:25:25 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
03/06/2023 and conducted by Evaluator Bethany Mirlohi
COMPLAINT CONTROL NUMBER: 59-AS-20230306135541
FACILITY NAME:OAKMONT OF WESTPARKFACILITY NUMBER:
315002955
ADMINISTRATOR:EDWARDS, ANTONETTEFACILITY TYPE:
740
ADDRESS:2400 PLEASANT GROVE BLVD.TELEPHONE:
(916) 545-8904
CITY:ROSEVILLESTATE: CAZIP CODE:
95747
CAPACITY:142CENSUS: 101DATE:
06/07/2023
UNANNOUNCEDTIME BEGAN:
02:30 PM
MET WITH:Lisa Velasco, Health Services DirectorTIME COMPLETED:
03:45 PM
ALLEGATION(S):
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Injections were not administered by an appropriately skilled professional.
Glucose testing was not performed by an appropriately skilled professional.
Facility is not responding timely to residents needs
INVESTIGATION FINDINGS:
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Licensing program Analyst (LPA) Bethany Mirlohi arrived unannounced to deliver complaint findings into allegations listed above. LPA met with Lisa Velasco during today’s inspection.
LPA investigated allegation, “Injections were not administered by an appropriately skilled professional” and “Glucose testing was not performed by an appropriately skilled professional”. LPA interviewed residents in care and learned that R1 receives insulin injections and Glucose testing from facility nurse. On February 20th 2023, R1 was due for her insulin injection and glucose testing at 8 pm. Facility did not have a nurse on shift that could provide the injection to resident until 10 pm.
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: 06/07/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/07/2023
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 59-AS-20230306135541
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: 315002955
VISIT DATE: 06/07/2023
NARRATIVE
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Therefore, the Medication technician brought R1 her injection and testing equipment and R1’s spouse(R2) completed the testing and injection for R1. LPA interviewed a staff member in which they stated they have an hour window before and after medication scheduled 8 PM time. Facility was unable to provide a nurse to the facility until 10 PM. Staff member stated R1’s spouse(R2) completed the testing and insulin injection on February 20th. Due to the information gathered, LPA finds allegation to be SUBSTANTIATED.
LPA investigated allegation, “Facility is not responding timely to resident’s needs.” LPA interviewed 4 residents and their spouses, interviewed staff, and reviewed resident documents. LPA interviewed residents in which 3 of 4 resident spouses stated they have had to provide their spouse care because staff were not responding to residents needs in a timely manner. Residents stated they have helped their spouse with continence care, and transfers to wheelchair to bed or wheelchair to toilet due to staff not responding in a timely manner. LPA interviewed staff in which they stated when caregivers call off, they do not have backup help and so they are unable to respond to call lights in a timely manner. LPA reviewed call light records and observed on March 20th 2023 R2 waited 40 minutes for a staff response when he was in the bathroom. On March 18th 2023 R2 waited 26 minutes for a staff response when he was in the bathroom. On March 15th 2023, R2 waited 33 minutes for a staff response when he was in the bathroom. On March 13th R2 waited 21 minutes for a staff response when he was in the dining room. On March 20th 2023, R3 waited 35 minutes for a staff response.

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

DATE: 06/07/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/07/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 6
Control Number 59-AS-20230306135541
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: 315002955
VISIT DATE: 06/07/2023
NARRATIVE
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On March 19th 2023 R3 pushed their pendant and records show “This alert was never responded to”. On March 17th 2023, R3 waited 29 minutes for staff to respond. On March 13th 2023, R3 pushed their pendant and records show, show “This alert was never responded to”. On March 15th 2023, R3 pushed their pendant and records show, show “This alert was never responded to”. On March 22nd 2023, R4 pushed their pendant and records show, show “This alert was never responded to”. On March 19th 2023, R4 waited 29 minutes for a staff response. On March 15th 2023, R4 pushed their pendant and records show, show “This alert was never responded to”. On March 13th 2023, R4 pushed their pendant and records show, show “This alert was never responded to”.
Due to the information gathered, LPA 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.

Exit interview conducted and appeal rights provided.
SUPERVISOR'S NAME: Troy OrdonezTELEPHONE: (916) 263-4832
LICENSING EVALUATOR NAME: Bethany MirlohiTELEPHONE: (916) 204-8288
LICENSING EVALUATOR SIGNATURE:

DATE: 06/07/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/07/2023
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
03/06/2023 and conducted by Evaluator Bethany Mirlohi
COMPLAINT CONTROL NUMBER: 59-AS-20230306135541

FACILITY NAME:OAKMONT OF WESTPARKFACILITY NUMBER:
315002955
ADMINISTRATOR:EDWARDS, ANTONETTEFACILITY TYPE:
740
ADDRESS:2400 PLEASANT GROVE BLVD.TELEPHONE:
(916) 545-8904
CITY:ROSEVILLESTATE: CAZIP CODE:
95747
CAPACITY:142CENSUS: 101DATE:
06/07/2023
UNANNOUNCEDTIME BEGAN:
02:30 PM
MET WITH:Lisa Velasco, Health Services DirectorTIME COMPLETED:
03:45 PM
ALLEGATION(S):
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Facility is mishandling medications
INVESTIGATION FINDINGS:
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Licensing program Analyst (LPA) Bethany Mirlohi arrived unannounced to deliver complaint findings into allegations listed above. LPA met with Lisa Velasco during today’s inspection.
LPA investigated allegation, “Facility is mishandling medications”. Relevant party stated that in the summer of 2022, R2’s diabetic testing strips were mailed to the facility and R2 and staff were not able to find the strips. R2 manages their own medication and supplies. Administrator stated that they never observed R2’s diabetic supplies. R2 stated they were mailed to the facility however they never received the testing strips. R2 indicated in May 2023 insulin syringes were mailed to the facility and again the staff lost their diabetic supplies.
Continutation 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: 06/07/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/07/2023
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 59-AS-20230306135541
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: 315002955
VISIT DATE: 06/07/2023
NARRATIVE
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R2 was able to show LPA a receipt that indicated a mail package was delivered to the facility, however the receipt did not indicate what items were delivered to facility. Administrator stated they looked for the package but they never observed a package for R2 during those time period. Due to the information gathered, 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.

Exit interview conducted.
SUPERVISOR'S NAME: Troy OrdonezTELEPHONE: (916) 263-4832
LICENSING EVALUATOR NAME: Bethany MirlohiTELEPHONE: (916) 204-8288
LICENSING EVALUATOR SIGNATURE:

DATE: 06/07/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/07/2023
LIC9099 (FAS) - (06/04)
Page: 5 of 6
Control Number 59-AS-20230306135541
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: 315002955
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/07/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Request Denied
Type A
06/12/2023
Section Cited
CCR
87629(b)(1)
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87629 Injections. (b) In addition to Section 87611, General Requirements for Allowable Health Conditions, the licensees who admit or retain residents who require injections shall be responsible for the following: (1) Ensuring that injections are administered by an appropriately skilled professional should the resident require assistance.
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Administrator agrees to submit a plan into CCL concerning how injections will be completed if there are staff/nurse call offs. Administrator to submit plan into CCL by 6/12/23.
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This requirment is not met as evidenced by: Based on interviews the licensee did not provide an appropriately skilled professional for R1's injections which poses an immediate health and safety risk to residents in care.
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Type B
06/19/2023
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. In facilities licensed for sixteen or more, sufficient support staff shall be employed to ensure provision of personal assistance and care as required in Section 87608, Postural Supports. Additional staff shall be employed as necessary to perform office work, cooking, house cleaning, laundering, and maintenance of buildings, equipment and grounds. The licensing agency may require any facility to provide additional staff whenever it determines through documentation that the needs of the particular residents, the extent of services provided, or the physical arrangements of the facility require such additional staff for the provision of adequate services.
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Administrator agrees to submit a plan in CCL concerning how they will respond to resident needs in a timely manner during a time of staff call offs. Administrator to submit plan into CCL by 6/19/2023.
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This requirement is not met as evidenced by: Based on interviews and record review the licensee did not did not provide sufficient staffing to met residents needs which poses a potential 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: 06/07/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/07/2023
LIC9099 (FAS) - (06/04)
Page: 6 of 6