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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700751
Report Date: 12/08/2022
Date Signed: 12/08/2022 05:21:34 PM


Document Has Been Signed on 12/08/2022 05:21 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
CCLD Regional Office, 520 COHASSET RD., STE. 170
CHICO, CA 95926



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: 74DATE:
12/08/2022
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
05:00 PM
MET WITH:Kathleen Gilbey, AdministratorTIME COMPLETED:
05:25 PM
NARRATIVE
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Licensing Program Analyst (LPA) Sabrina Calzada arrived unannounced to conduct a follow up case management inspection related to a deficiency discovered during complaint investigation #25-AS-20220519170123. LPA met with Administrator, Kathleen Gilbey, and explained purpose of inspection. Prior to initiating today's inspection, LPA completed required COVID-19 testing protocols and completed a daily self-screening questionnaire for symptoms of COVID-19 infection to affirm no COVID-19 related symptoms. Additionally, LPA was screened per Covid-19 precautionary measures upon entering the community. LPA ensured she applied hand sanitizer before entering the facility and the following Personal Protective Equipment (PPE) was worn: surgical mask

During the investigation, Medication Administration Records (MAR) were reviewed for months April- September 2022 for resident (R1), the subject of the complaint investigation. On 10/11/22, LPA also reviewed (3) staff files and training records and interviewed staff (S1). Staff (S1) stated to LPA on 10/11/22 that they have completed (8) hours of initial medication training but had not completed medication shadowing hours as required. MAR for July 2022 shows S1 administered medications to R1 on 7/2/22 and on 7/10/22. Staff training records show that staff (S2) had completed (8) hours of initial medication training on 7/10/2022 but had also not completed the required initial (16) hours of medication shadowing. MAR for July 2022 shows S2 administered medications several times from 7/20/22- 7/30/22, in August 2022 and September 2022 for R1.

Records review shows staff (S3) had not completed (8) hours of continuing in-service medication training required within the last 12 months. MAR records show S3 consistently administered medications to R1 from April 2022- August 2022.

Per California Code of Regulations, Title 22, Division 6, Chapter 8, the following (2) citations are issued on the 809D page.

Exit interview. Copy of report and appeal rights provided.
SUPERVISOR'S NAME: Maribeth SentyTELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Sabrina CalzadaTELEPHONE: (510) 829-2133
LICENSING EVALUATOR SIGNATURE:
DATE: 12/08/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/08/2022
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 2


Document Has Been Signed on 12/08/2022 05:21 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
CCLD Regional Office, 520 COHASSET RD., STE. 170
CHICO, CA 95926


FACILITY NAME: OAKMONT OF CARMICHAEL
FACILITY NUMBER: 342700751

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/08/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
01/16/2023
Section Cited

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§1569.69 Employees assisting residents with self-administration of medication; training requirements. (a) Each residential care facility for the elderly licensed under this chapter shall ensure that each employee of the facility who assists residents with the self-administration of medications meets all of the following training requirements:
(3) An employee shall be required to complete the training requirements for hands-on shadowing training described in this subdivision prior to assisting any resident in the self-administration of medications. The training and instruction described in this subdivision shall be completed, in their entirety, within the first two weeks of employment. This requirement is not met as evidenced by:
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Based on record review and interview conducted, the Licensee did not ensure that staff (S1 and S2) had the required initial shadow training prior to administering medications, posing a potential health and safety risk to residents in care.
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Type B
01/16/2023
Section Cited

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§1569.69 Employees assisting residents with self-administration of medication; training requirements: (b) Each employee who received training and passed the examination required in paragraph (5) of subdivision (a), and who continues to assist with the self-administration of medicines, shall also complete eight hours of in-service training on medication-related issues in each succeeding 12-month period. This requirement is not met as evidenced by:
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Based on record review, the Licensee did not ensure that staff (S3)had completed the required ongoing medication training within the last 12 months from when the review was conducted on 10/11/22, posing 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: Maribeth SentyTELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Sabrina CalzadaTELEPHONE: (510) 829-2133
LICENSING EVALUATOR SIGNATURE:
DATE: 12/08/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/08/2022
LIC809 (FAS) - (06/04)
Page: 2 of 2