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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 342700751
Report Date: 12/01/2023
Date Signed: 12/01/2023 03:05:48 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
09/18/2023 and conducted by Evaluator Angela Hood
COMPLAINT CONTROL NUMBER: 59-AS-20230918125748
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: 69DATE:
12/01/2023
UNANNOUNCEDTIME BEGAN:
11:25 AM
MET WITH:Kathleen Gilbey, Executive DirectorTIME COMPLETED:
03:10 PM
ALLEGATION(S):
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-Staff do not ensure records are properly maintained
-Staff do not ensure care needs of resident are being properly met
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Angela Hood arrived unannounced at the care home today, 12/1/23, and met with the Executive Director, Kathleen Gilbey, to deliver complaint investigation findings into the above listed allegations.

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

Allegations: Staff do not ensure records are properly maintained and staff do not ensure care needs of resident are being properly met.
The relevant party indicated that staff were not documenting when hourly checks were being conducted for resident (R1). The log being used to document the hourly checks was being pre-filled by staff. Also, staff were not responding timely or at all when R1 would push their call button on their pendant.
*********************************************Continued on LIC9099-C***************************************************
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Maribeth SentyTELEPHONE: (916) 214-0485
LICENSING EVALUATOR NAME: Angela HoodTELEPHONE: 650-676-0390
LICENSING EVALUATOR SIGNATURE:

DATE: 12/01/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/01/2023
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 7
Control Number 59-AS-20230918125748
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: 12/01/2023
NARRATIVE
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Interview with the Executive Director (ED) indicated that the facility put in place a temporary plan of care for R1 requiring staff to conduct hourly checks due to the possibility that the call button pendants were not functioning properly in the memory care unit of the facility. Email correspondence between the ED and R1’s responsible party, dated 8/28/23, indicated that the facility will immediately begin conducting hourly checks on R1 until the facility is able to have a diagnostic check conducted on the emergency call button system. The ED indicated that a sign-in sheet was created to log the hourly checks and staff were instructed that it is necessary for them to record their hourly checks.

Interviews conducted with staff (S1 & S2) indicated that care staff are to conduct hourly checks on R1 and fill out the log for the time the check was completed. Interviews also indicated that neither S1 nor S2 were aware of any care staff pre-filling the log before completing their hourly checks. Interview with S2 indicated that the hourly checks were a part of R1’s ADL/care plan until R1 moved out of the facility. According to R1’s care plan dated November 2023, R1 is to have status checks conducted 24 times per day.

The facility provided the Department with the hourly check sign-in logs dated 8/28/23-9/18/23. There were several entries that were missing from the provided logs. Between 8/29/23 at 9:30pm to 8/30/23 at 2:30pm, there were no records of staff conducting hourly checks on R1. Between 9/1/23 at 5:30pm to 9/2/23 at 12:00pm, there were no records of hourly checks conducted. On 9/2/23, there were no entries between 6:12pm-10:40pm. On 9/3/23, there were no entries between 5:45am-7:05am, as well as 8:16am-10:20am. On 9/8/23, there were no entries between 12am-5am. On 9/11/23, there were no entries between 12pm-1pm. On 11/7/23, LPA conducted a visit at the care home and requested the facility provide documentation for the missing entries on the hourly check log. LPA was informed that the facility does not have any additional documentation to provide.

According to the facility’s Emergency Response Systems Policies and Procedures dated October 2014, the care providers in the care home carry pagers. “When an alert is received on the pager the care provider will note if the alert is coming from one of their assigned residents and respond to the alert. If the care provider cannot promptly answer the alert because he/she is attending to another resident and cannot safely breakaway to answer the alert, the care provider will utilize their radio to request that another available care provider respond to the alert. The available care provider will acknowledge the request”.
************************************************Continued on LIC9099-C*************************************************
SUPERVISOR'S NAME: Maribeth SentyTELEPHONE: (916) 214-0485
LICENSING EVALUATOR NAME: Angela HoodTELEPHONE: 650-676-0390
LICENSING EVALUATOR SIGNATURE:

DATE: 12/01/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/01/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 7
Control Number 59-AS-20230918125748
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: 12/01/2023
NARRATIVE
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Interview with the Vice President of Operations (VPO) indicated that there is no formal policy indicating an expected response time for staff to respond to a residents’ call button. VPO indicated that the facility’s expectation is for staff to respond immediately and that residents should not be waiting more than 15 minutes for a response from care staff. Interview with S2 indicated that staff are to respond to the call buttons right away. S2 indicated that, when care staff cannot respond to a call, they will reach out to another care staff member to respond. Interview with S1 indicated that the caregivers have pagers to inform them when a call button was pushed. Interview with R1 indicated that staff do not always come when they push their call button. R1 stated that staff have been better lately. R1 stated that maybe there are times when care staff are not available to respond to their call for assistance.

According to the SMARTcare call button alert history dated between 9/13/23-9/18/23, there were 19 instances where care staff responded to residents’ calls for assistance between 26-42 minutes. There were an additional 16 instances where the alerts were never responded to. Between 9/13/23-9/18/23, there were 7 occasions that care staff responded to R1’s call button between 26 mins-35 mins and 11 occasions that the alerts were never responded to. Resident (R4) had 2 calls with a response time between 28-42 minutes and 3 alerts that were never responded to. Resident (R5) had 3 calls with a response time between 27-40 minutes. Resident (R6) had 3 calls with a response time between 34-41 minutes.

Based on interviews conducted by the department 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 conducted. A copy of this report and appeal rights were provided. Signature on these forms acknowledges receipt of these documents.
SUPERVISOR'S NAME: Maribeth SentyTELEPHONE: (916) 214-0485
LICENSING EVALUATOR NAME: Angela HoodTELEPHONE: 650-676-0390
LICENSING EVALUATOR SIGNATURE:

DATE: 12/01/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/01/2023
LIC9099 (FAS) - (06/04)
Page: 3 of 7
Control Number 59-AS-20230918125748
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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/01/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Request Denied
Type B
12/15/2023
Section Cited
CCR
87506(a)
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87506 Resident Records (a)The licensee shall ensure that a separate, complete, and current record is maintained for each resident in the facility or in a central administrative location readily available to facility staff and to licensing agency staff.
This requirement is not met as evidenced by:
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Facility agrees to submit a statement of understanding as well as conduct a staff training to ensure staff understand the importance of documentation. Facility will also submit a list of all staff who attended the training by the POC due date of 12/15/23.

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Based on interviews conducted and documentation reviewed, the facility did not ensure R1’s records were maintained for hourly checks conducted, which poses a potential health, safety, and personal rights risk to residents in care.



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Request Denied
Type B
12/15/2023
Section Cited
CCR
87464(f)(1)
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87464 Basic Services (f) Basic services shall at a minimum include: (1) Care and supervision as defined in Section 87101(c)(3) and Health and Safety Code section 1569.2(c).
This requirement is not met as evidenced by:
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Facility agrees to submit a statement of understanding as well as conduct a staff training to ensure staff understand the caregiver expectations. Facility will also submit a list of all staff who attended the training by the POC due date of 12/15/23.
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Based on interviews conducted and records reviewed, the facility did not ensure that R1 was receiving hourly checks or that residents’ call button alerts were responded to in a timely manner, 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: Maribeth SentyTELEPHONE: (916) 214-0485
LICENSING EVALUATOR NAME: Angela HoodTELEPHONE: 650-676-0390
LICENSING EVALUATOR SIGNATURE:

DATE: 12/01/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/01/2023
LIC9099 (FAS) - (06/04)
Page: 4 of 7
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
09/18/2023 and conducted by Evaluator Angela Hood
COMPLAINT CONTROL NUMBER: 59-AS-20230918125748

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: DATE:
12/01/2023
UNANNOUNCEDTIME BEGAN:
11:25 AM
MET WITH:Kathleen Gilbey, Executive DirectorTIME COMPLETED:
03:10 PM
ALLEGATION(S):
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9
-Licensee does not ensure call signal system is in good repair
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Angela Hood arrived unannounced at the care home today, 12/1/23, and met with the Executive Director, Kathleen Gilbey, to deliver complaint investigation findings into the above listed allegations.

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

Allegation: Licensee does not ensure call signal system is in good repair.
The relevant party indicated that the facility call response system was not functioning properly in the memory care unit due to internet connectivity. Interview with the Executive Director (ED) indicated that the facility had contacted Lifeline call button company, Phillips, on 8/28/23 to schedule an appointment for 9/13/23 to conduct a diagnostic of the call button system to ensure it was working properly.
********************************************Continued on LIC9099-C***************************************************
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Maribeth SentyTELEPHONE: (916) 214-0485
LICENSING EVALUATOR NAME: Angela HoodTELEPHONE: 650-676-0390
LICENSING EVALUATOR SIGNATURE:

DATE: 12/01/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/01/2023
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 7
Control Number 59-AS-20230918125748
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: 12/01/2023
NARRATIVE
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Interview with facility maintenance staff indicated that Phillips checked the call button system on 9/13/23 to ensure it was functioning in the memory care unit. Maintenance staff indicated that the pendants were checked and were all working properly. Maintenance staff completes a check of the pendants, egress, and wander guards for the facility monthly.

According to the Lifeline report provided to the facility by Phillips on 9/13/23, Phillips conducted 3 checks in both memory care and assisted living and confirmed that all pagers were receiving calls in the facility. Interview with residents (R2 & R3) indicated that their call button pendants work properly.

Based on interviews conducted 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 conducted. A copy of this report was provided.
SUPERVISOR'S NAME: Maribeth SentyTELEPHONE: (916) 214-0485
LICENSING EVALUATOR NAME: Angela HoodTELEPHONE: 650-676-0390
LICENSING EVALUATOR SIGNATURE:

DATE: 12/01/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/01/2023
LIC9099 (FAS) - (06/04)
Page: 6 of 7
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
09/18/2023 and conducted by Evaluator Angela Hood
COMPLAINT CONTROL NUMBER: 59-AS-20230918125748

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: DATE:
12/01/2023
UNANNOUNCEDTIME BEGAN:
11:25 AM
MET WITH:Kathleen Gilbey, Executive DirectorTIME COMPLETED:
03:10 PM
ALLEGATION(S):
1
2
3
4
5
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9
-Staff do not ensure residents room is kept unlocked at all times
INVESTIGATION FINDINGS:
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3
4
5
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Licensing Program Analyst (LPA) Angela Hood arrived unannounced at the care home today, 12/1/23, and met with the Executive Director, Kathleen Gilbey, to deliver complaint investigation findings into the above listed allegations.

Allegation: Staff do not ensure residents room is kept unlocked at all times.
Interview with relevant party indicated that there was no concern regarding staff not ensuring that resident (R1’s) room is kept unlocked at all times. R1 resided in the memory care unit of the facility. Interview with the Executive Director (ED) indicated that the apartment doors in the memory care unit are typically kept locked due to residents wandering into other residents’ rooms. ED indicated that residents may also take other residents’ belongings or leave their belongings in the wrong apartment. ED stated that when a resident wants to return to their room, a care staff will unlock the door for them. Interview with R1 indicated that they are able to get into their room when they ask for staff to open the door.

Based on interviews, 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.
Unfounded
Estimated Days of Completion:
SUPERVISOR'S NAME: Maribeth SentyTELEPHONE: (916) 214-0485
LICENSING EVALUATOR NAME: Angela HoodTELEPHONE: 650-676-0390
LICENSING EVALUATOR SIGNATURE:

DATE: 12/01/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/01/2023
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 7