342700751-4-12-2023-25-AS-KHOS-CR2NFK-20230419102540

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 342700751
Report Date: 04/12/2023
Date Signed: 04/12/2023 02:15:18 PM

Unsubstantiated

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
12/27/2022 and conducted by Evaluator Kevin Mknelly

COMPLAINT CONTROL NUMBER: 25-AS-20221227151037

FACILITY NAME:	OAKMONT OF CARMICHAEL		FACILITY NUMBER:	342700751
ADMINISTRATOR:	KATHLEEN GILBEY		FACILITY TYPE:	740
ADDRESS:	4717 ENGLE ROAD		TELEPHONE:	(916) 483-3800
CITY:	CARMICHAEL	STATE: CA	ZIP CODE:	95608
CAPACITY:	101	CENSUS: 7	DATE:	04/12/2023
		UNANNOUNCED	TIME BEGAN:	11:00 AM
MET WITH:	Kathleen Gilbey		TIME COMPLETED:	02:15 PM

ALLEGATION(S):

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Resident sustained injuries from a fall while in care due to lack of supervision.

INVESTIGATION FINDINGS:

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On 4/12/23, Licensing Program Analyst (LPA) Kevin Mknelly arrived, met with the Executive Director, and explained the reason for the visit. The purpose of this inspection was to investigate the allegations sited above.

Licensing Program Analyst (LPA) Kevin Mknelly received copies of the following: the internal incident report of a fall by R1 on 12/18/22 (recorded previously as 12/19/22- 12/18/23 is the correct date), Hospice record of care provided for the injuries from that fall, name of the caregiver(s) who attended to R1 or witnessed the incident (if no longer employed, contact information on record) if still employed, April 2023 work schedules.

LPA observed R1 receiving assistance while dining. LPA interviewed 4 staff and a hospice RN.

Hospice Visit notes for R1, on 12/18/22 note "...new laceration... roughly 1 cm long... wound started to scab... no signs of bleeding or infection... cleaned... ATB ointment applied..." - Report continued

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Maribeth Senty	TELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Kevin Mknelly	TELEPHONE: (209) 814-1925
LICENSING EVALUATOR SIGNATURE:	DATE: 04/12/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/12/2023

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 25-AS-20221227151037

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 CARMICHAEL	FACILITY NUMBER: 342700751
	VISIT DATE: 04/12/2023

NARRATIVE

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Hospice records showed that the wheelchair used by R1 on 12/18/23 was newly provided and was delivered without the proper cushion for positioning.

Interviews found that 4 staff were present conducting a shift change briefing and that R1 was seated in their wheelchair approximately ten(10) feet away, partially obscured by a post, at the time of R1's fall . According to staff statements, R1 had not made any typical vocalizations of distress or discomfort prior to staff hearing a fall had occurred. When the briefing took place, statements indicate R1 to be seated nearby quietly and not in need of assistance.

Evidence suggests that R1 had moved unexpectedly and without warning resulting in an accidental fall. R1 was not requiring 1:1 staffing. Staff present responded immediately after the fall to provide first aid. Hospice was notified promptly and R1 was seen by hospice 12/18/23.

As a result of this investigation, LPA finds allegation to be (US)Unsubstantiated - A finding that the complaint 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 with administrator.

SUPERVISOR'S NAME: Maribeth Senty	TELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Kevin Mknelly	TELEPHONE: (209) 814-1925
LICENSING EVALUATOR SIGNATURE:	DATE: 04/12/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/12/2023

LIC9099 (FAS) - (06/04)

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