342700751-1-11-2024-59-AS-MSEY-CZKTJS-20240117134650

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 342700751
Report Date: 01/11/2024
Date Signed: 01/11/2024 03:55:07 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, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

This is an official report of an unannounced visit/investigation of a complaint received in our office on
09/27/2023 and conducted by Evaluator Angela Hood

COMPLAINT CONTROL NUMBER: 59-AS-20230927093334

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:	DATE:	01/11/2024
		UNANNOUNCED	TIME BEGAN:	01:25 PM
MET WITH:	Luis Olivas, Executive Director		TIME COMPLETED:	04:10 PM

ALLEGATION(S):

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-Staff are not providing adequate care and supervision to residents

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Angela Hood arrived at the care home today, 1/11/24, and met with the Executive Director, Luis Olivas, to deliver complaint investigation findings into the allegation listed above.

During a separate complaint investigation #59-AS-20230918125748 concluded on 12/1/23, it was discovered that care staff did not ensure that resident (R7) was receiving hourly checks as indicated in their care plan. It was also discovered that residents’ call button alerts were not responded to in a timely manner.

Due to facility receiving a citation regarding the same violation in a separate complaint investigation conducted on 12/1/23, no additional citations will be issued regarding allegation.

Based on interviews conducted and records reviewed, the preponderance of evidence standards have been met. Therefore, the above allegation was found to be SUBSTANTIATED. Per California Code of Regulations, Title 22, Division 6, Chapter 8, deficiencies were cited during a separate complaint investigation conducted on 12/1/23 regarding the same violation.

Exit interview conducted. Copy of report provided.

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Maribeth Senty	TELEPHONE: (916) 214-0485
LICENSING EVALUATOR NAME: Angela Hood	TELEPHONE: 650-676-0390
LICENSING EVALUATOR SIGNATURE:	DATE: 01/11/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/11/2024

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

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

This is an official report of an unannounced visit/investigation of a complaint received in our office on
09/27/2023 and conducted by Evaluator Angela Hood

COMPLAINT CONTROL NUMBER: 59-AS-20230927093334

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:	DATE:	01/11/2024
		UNANNOUNCED	TIME BEGAN:	01:25 PM
MET WITH:	Luis Olivas, Executive Director		TIME COMPLETED:	04:10 PM

ALLEGATION(S):

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-Staff mishandled a resident's medication while in care
-Staff screamed at a resident while in care

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Angela Hood arrived at the care home today, 1/11/24, and met with the Executive Director, Luis Olivas, to deliver complaint investigation findings into the allegations listed above.

During the course of the investigation, LPA conducted a medication count, conducted interviews, and obtained documentation pertinent to the investigation.

Allegation: Staff mishandled a resident’s medication while in care
According to interviews with hospice nurses, when a resident is placed on hospice, the nurse and residents’ physician coordinate to get medications filled. According to resident (R1’s) admission agreement, they were

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Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Maribeth Senty	TELEPHONE: (916) 214-0485
LICENSING EVALUATOR NAME: Angela Hood	TELEPHONE: 650-676-0390
LICENSING EVALUATOR SIGNATURE:	DATE: 01/11/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/11/2024

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

LIC9099 (FAS) - (06/04)

Page: 2 of 6

Control Number 59-AS-20230927093334

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: OAKMONT OF CARMICHAEL	FACILITY NUMBER: 342700751
	VISIT DATE: 01/11/2024

NARRATIVE

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admitted to the care home on 9/10/23. Interviews with hospice nurses indicated that R1 began receiving hospice care services on 9/11/23. Interview with hospice nurse indicated that R1’s admission nurse arrived at the care home at 5pm on 9/11/23. Interview indicated that the admission nurse started R1’s medication list and ordered medications that were not present at the care home. According to interview, the orders were made after hours at 5pm on 9/11/23. Hospice nurse indicated that, because the order was made after hours, the medications should have arrived at the care home on 9/12/23 or 9/13/23. Hospice nurse indicated that there were no flags for late delivery of medication on R1’s chart. Interview indicated that R1’s first hospice case management visit was on 9/13/23 at 11am. Hospice nurse indicated that R1’s prescription for Seroquel was increased and made into a scheduled medication instead of a PRN. Interview indicated that an order for the Seroquel was placed at Rite Aid so that R1 could receive the medication right away. Any additional medications were ordered through the facility’s pharmacy.

Interview with staff (S2) indicated that, when the hospice nurse arrived for R1’s first case management visit, they were trying to determine if R1’s medications had been ordered. S2 indicated that R1 still needed some of their medications filled. S2 stated the hospice nurse reordered medications for R1. S2 indicated that R1’s responsible party ordered the prescriptions through Rite Aid so R1 could receive the medications immediately. Interview with the Health Services Director indicated that R1’s responsible party was going to pick up any needed medications from the pharmacy and bring them to the facility later that day, 9/13/23. Interviews with S2 and staff (S3) indicated that R1 received their medications while at the care home. S2 indicated that medications waiting to be filled were not received. According to interviews, R1 moved out of the care home later in the day on 9/13/23.

On 11/7/23, LPA conducted a medication count for residents (R4, R5, & R6) comparing medications to the facility’s Centrally Stored Medications forms. LPA did not observe any errors when comparing R4, R5, and R6’s medications that were counted to the Centrally Stored Medication forms. Interviews with residents (R2 & R3) indicated that they are receiving medications as prescribed.

Allegation: Staff screamed at a resident while in care
Interviews conducted with Memory Care Director, staff (S1), S2, and S3 indicated that they have never witnessed staff yell or scream at R1. S1 indicated that, if they witnessed staff scream at a resident, they
************************************************Continued on LIC9099-C**********************************************

SUPERVISOR'S NAME: Maribeth Senty	TELEPHONE: (916) 214-0485
LICENSING EVALUATOR NAME: Angela Hood	TELEPHONE: 650-676-0390
LICENSING EVALUATOR SIGNATURE:	DATE: 01/11/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/11/2024

LIC9099 (FAS) - (06/04)

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Control Number 59-AS-20230927093334

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: OAKMONT OF CARMICHAEL	FACILITY NUMBER: 342700751
	VISIT DATE: 01/11/2024

NARRATIVE

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would let the Executive Director know. S2 and staff (S5) indicated that there was always another staff present in R1’s room, whether that be another care staff or hospice care staff. Interviews with S1, S3, staff (S4), and S5 indicated that they have never witnessed staff scream or yell at any residents in care.

Interviews with R2 and R3 indicated that they have never witnessed staff mistreat residents in care. R2 and R3 indicated that they have never witnessed staff yell at residents in care. R2 indicated that staff treat them well.

Based on medication count, interviews conducted, and records reviewed, the preponderance of evidence standards have not been met. Therefore, the above allegations were 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 conducted. A copy of this report was provided.

SUPERVISOR'S NAME: Maribeth Senty	TELEPHONE: (916) 214-0485
LICENSING EVALUATOR NAME: Angela Hood	TELEPHONE: 650-676-0390
LICENSING EVALUATOR SIGNATURE:	DATE: 01/11/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/11/2024

LIC9099 (FAS) - (06/04)

Page: 4 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, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

This is an official report of an unannounced visit/investigation of a complaint received in our office on
09/27/2023 and conducted by Evaluator Angela Hood

COMPLAINT CONTROL NUMBER: 59-AS-20230927093334

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:	DATE:	01/11/2024
		UNANNOUNCED	TIME BEGAN:	01:25 PM
MET WITH:	Luis Olivas, Executive Director		TIME COMPLETED:	04:10 PM

ALLEGATION(S):

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-Staff did not issue a refund

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Angela Hood arrived at the care home today, 1/11/24, and met with the Executive Director, Luis Olivas, to deliver complaint investigation findings into the allegation listed above.

During the course of the investigation, LPA conducted interviews and obtained documentation pertinent to the investigation.

Allegation: Staff did not issue a refund
Interview with the Executive Director (ED) indicated that resident (R1’s) responsible party was refunded after R1 moved out of the care home. ED indicated that R1’s responsible party had provided the care home with a 30-day notice via email on 9/12/23. ED stated that R1’s responsible party removed R1 from the care home
on 9/13/23 without informing staff and R1 did not return to the care home. ED indicated that they emailed
R1’s responsible party on 9/21/23 indicating that the facility will be issuing a refund, less the rent and care
***********************************************Continued on LIC9099-C************************************************

Unfounded

Estimated Days of Completion:

SUPERVISOR'S NAME: Maribeth Senty	TELEPHONE: (916) 214-0485
LICENSING EVALUATOR NAME: Angela Hood	TELEPHONE: 650-676-0390
LICENSING EVALUATOR SIGNATURE:	DATE: 01/11/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/11/2024

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

LIC9099 (FAS) - (06/04)

Page: 5 of 6

Control Number 59-AS-20230927093334

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: OAKMONT OF CARMICHAEL	FACILITY NUMBER: 342700751
	VISIT DATE: 01/11/2024

NARRATIVE

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for the two days that R1 was at the care home, as well as the $500 initial assessment fee. ED indicated that a refund check was printed by the facility on 9/22/23. ED indicated that the check was mailed via FedEx Priority Overnight mail to the responsible party on 9/28/23 and delivered on 9/29/23. ED stated that the care home originally had the wrong address for R1’s responsible party so they called to verify to ensure they had the correct address to send the check.

ED provided LPA with the email correspondence with R1’s responsible party including the 30-day notice to vacate that was sent to the facility on 9/12/23. Also, ED provided LPA with email correspondence to R1’s responsible party sent from the ED on 9/21/23 indicating that the facility will be issuing a full refund, less the rent for the two days R1 was at the care home and $500 for the initial assessment. LPA received a copy of the check that was issued on 9/22/23, as well as a copy of the FedEx proof of delivery receipt showing the delivery was successful on 9/29/23.

Based on interviews conducted and records reviewed, the above allegation is found to be UNFOUNDED. A finding that the allegation is unfounded means that the allegation is false, could not have happened, and/or is without a reasonable basis.

Exit interview conducted. A copy of this report was provided.

SUPERVISOR'S NAME: Maribeth Senty	TELEPHONE: (916) 214-0485
LICENSING EVALUATOR NAME: Angela Hood	TELEPHONE: 650-676-0390
LICENSING EVALUATOR SIGNATURE:	DATE: 01/11/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/11/2024

LIC9099 (FAS) - (06/04)

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