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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700751
Report Date: 04/07/2023
Date Signed: 04/07/2023 03:10:36 PM


Document Has Been Signed on 04/07/2023 03:10 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		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 CARMICHAELFACILITY NUMBER:
342700751
ADMINISTRATOR:KATHLEEN GILBEYFACILITY TYPE:
740
ADDRESS:4717 ENGLE ROADTELEPHONE:
(916) 483-3800
CITY:CARMICHAELSTATE: CAZIP CODE:
95608
CAPACITY:101CENSUS: 72DATE:
04/07/2023
TYPE OF VISIT:Case Management - Annual ContinuationUNANNOUNCEDTIME BEGAN:
11:15 AM
MET WITH:Kathleen GilbeyTIME COMPLETED:
02:15 PM
NARRATIVE
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Licensing Program Analyst (LPA) Kevin Mknelly arrived at the facility unannounced on 4/7/23 to conduct a Continued Annual Inspection. LPAs met with Executive Director and explained the purpose of the visit.

LPA completed Resident file reviews during this visit.
Inspection found three(3) of six(6 residents with physician's reports out of date.

As a result of this investigation, LPA finds allegation 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. The following deficiencies were cited on 9099-D, per Title 22 Regulations, Division 6. (A)This poses an immediate Health and Safety risk to clients/residents in care. (B) This poses a potential Health and Safety risk, or personal rights violation, to clients/residents in care.



Exit interview conducted and copy of report and appeal rights left at the facility.
SUPERVISOR'S NAME: Maribeth SentyTELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Kevin MknellyTELEPHONE: (209) 814-1925
LICENSING EVALUATOR SIGNATURE:
DATE: 04/07/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/07/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 4


Document Has Been Signed on 04/07/2023 03:10 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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 CARMICHAEL
FACILITY NUMBER: 342700751

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/07/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87705(c)(5)(A)
Care of Persons with Dementia
(c) Licensees who accept and retain residents with dementia shall be responsible for ensuring the following: (5) Each resident with dementia shall have an annual medical assessment as specified in Section 87458, Medical Assessment, and a reappraisal done at least annually, both of which shall include a reassessment of the resident's dementia care needs. (A) When any medical assessment, appraisal, or observation indicates that the resident's dementia care needs have changed, corresponding changes shall be made in the care and supervision provided to that resident.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on records review, the licensee did not comply with the section cited above inInspection found three(3) of six(6) residents, R1, R3 and 5 with physician's reports out of date.which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/28/2023
Plan of Correction
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Licensee agrees to submit LIC 602's for the residents identified, after confirming accuracy, by the POC date of 4/28/23.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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: Maribeth SentyTELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Kevin MknellyTELEPHONE: (209) 814-1925
LICENSING EVALUATOR SIGNATURE:
DATE: 04/07/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/07/2023
LIC809 (FAS) - (06/04)
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