342700796-12-1-2021-27-AS-KHOS-C9QKBG-20211215064528

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 342700796
Report Date: 12/01/2021
Date Signed: 12/01/2021 12:39:18 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 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
11/02/2021 and conducted by Evaluator Christopher Hopkins-Clarke

PUBLIC

COMPLAINT CONTROL NUMBER: 27-AS-20211102154417

FACILITY NAME:	OAKMONT OF EAST SACRAMENTO		FACILITY NUMBER:	342700796
ADMINISTRATOR:	ERVIN, TERENCE		FACILITY TYPE:	740
ADDRESS:	5301 F STREET		TELEPHONE:	(916) 905-2400
CITY:	EAST SACRAMENTO	STATE: CA	ZIP CODE:	95819
CAPACITY:	214	CENSUS: 138	DATE:	12/01/2021
		UNANNOUNCED	TIME BEGAN:	09:25 AM
MET WITH:	Terry Ervin		TIME COMPLETED:	12:45 PM

ALLEGATION(S):

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-Staff did not follow resident's care plan.
-Resident sustained injuries while in care.
-Resident was left in soiled diaper for extended period of time
-Staff took away resident's pendant

INVESTIGATION FINDINGS:

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On December 1, 2021 at 9:25am Licensing Program Analyst (LPA) Chris Hopkins conducted an unannounced complaint visit. LPA met with Administrator Terry Ervin and explained the purpose of the visit.

Regarding the allegation of Staff did not follow resident's care plan, the Department found the following: based on interviews and record review, caretakers logged in the resident 1's (R1) care log of when R1 recieved his/her daily care. R1 had a private caregiver starting at 7am and ending at 5pm. Facility caretakers still would help out throughout the day. R1's care log reflects his/her needs and services plan as well.

Regarding the allegation of Resident sustained injuries while in care, the Department found the following: based on interview and record review, R1 never sustained any injuries from his falls. Caretakers assessed him and there were no injuries reported. LPA reviewed R1's care notes and it stated R1 did have some slight pain/discomfort from his/her fall on 10/20/21.
Report continued on LIC 9099-C...

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Czarrina A Camilon-Lee	TELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Christopher Hopkins-Clarke	TELEPHONE: (916) 263-4700
LICENSING EVALUATOR SIGNATURE:	DATE: 12/01/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/01/2021

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 4

Control Number 27-AS-20211102154417

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

FACILITY NAME: OAKMONT OF EAST SACRAMENTO	FACILITY NUMBER: 342700796
	VISIT DATE: 12/01/2021

NARRATIVE

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R1 did request for some type of topical cream or ointment for the pain. It was noted in the care notes that R1's doctor was contacted for this. On the same day during the night shift it was noted that R1 was alert and there was no complaint of pain or discomfort, and caretakers would continue to monitor.

Regarding the allegation of Resident was left in soiled diaper for extended period of time, the Department found the following: based on interview and record review R1 was changed twice everyday during the NOC shift. R1's care log shows this as well. R1 also had special instructions in his/her care plan regarding urine bottles being next to his/her bed. R1 moved out at the end of October 2021, so LPA was not able to visually see R1. LPA interviewed other residents and responsible parties, who stated that caretakers are great about changing their loved ones.

Regarding the allegation of Staff took away resident's pendant, the Department found the following: based on interview, R1 had his pendant the whole time until he/she moved out. LPA spoke to NOC shift caretaker who stated R1 had the necklace pendant. LPA also spoke to Assistant Executive Director who stated R1 had his/her pendant until the day R1 moved out.

LPA has deemed the four allegations mentioned above as UNSUBSTANTIATED. Although the allegations may have happened and/or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are UNSUBSTANTIATED.

Exit interview conducted with Administrator Terry Ervin. A copy of this report was left with Administrator upon exit.

SUPERVISOR'S NAME: Czarrina A Camilon-Lee	TELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Christopher Hopkins-Clarke	TELEPHONE: (916) 263-4700
LICENSING EVALUATOR SIGNATURE:	DATE: 12/01/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/01/2021

LIC9099 (FAS) - (06/04)

Page: 2 of 4

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 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
11/02/2021 and conducted by Evaluator Christopher Hopkins-Clarke

PUBLIC

COMPLAINT CONTROL NUMBER: 27-AS-20211102154417

FACILITY NAME:	OAKMONT OF EAST SACRAMENTO		FACILITY NUMBER:	342700796
ADMINISTRATOR:	ERVIN, TERENCE		FACILITY TYPE:	740
ADDRESS:	5301 F STREET		TELEPHONE:	(916) 905-2400
CITY:	EAST SACRAMENTO	STATE: CA	ZIP CODE:	95819
CAPACITY:	214	CENSUS: 138	DATE:	12/01/2021
		UNANNOUNCED	TIME BEGAN:	09:25 AM
MET WITH:	Terry Ervin		TIME COMPLETED:	12:45 PM

ALLEGATION(S):

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-Resident's responsible person was not notified of resident's incident.

INVESTIGATION FINDINGS:

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On December 1, 2021 at 9:25am Licensing Program Analyst (LPA) Chris Hopkins conducted an unannounced complaint visit. LPA met with Administrator Terry Ervin and explained the purpose of the visit.

Regarding the allegation of Resident's responsible person was not notified of resident's incident, the Department found the following: based on interview and record review, it was noted in R1's care notes that R1 had two falls, both were unwitnessed but caretakers found him on the ground. LPA requested Incident reports for both of these incidents, but Administrator and Care Director could not provide them. R1's care notes state that R1's family was contacted but there is no proof of that, as an Incident Report to the Department would prove this. R1's responsible stated he/she never was made aware of any falls.

Based on interview and record review, the preponderance of evidence standards has been met, therefore, the above allegation(s) is/are found to be SUBSTANTIATED. Per California Code of Regulations, Title 22 Division 6, Chapter 8, deficiencies are being cited on the attached 9099D during this visit. Exit interview held, Appeal Rights discussed and given, Copy of report given.

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Czarrina A Camilon-Lee	TELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Christopher Hopkins-Clarke	TELEPHONE: (916) 263-4700
LICENSING EVALUATOR SIGNATURE:	DATE: 12/01/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/01/2021

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

LIC9099 (FAS) - (06/04)

Page: 3 of 4

Control Number 27-AS-20211102154417

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

FACILITY NAME: OAKMONT OF EAST SACRAMENTO	FACILITY NUMBER: 342700796
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 12/01/2021

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 12/08/2021 Section Cited CCR 87211(a)(1)	1 2 3 4 5 6 7	Reporting Requirements 87211(a)(1): (a) Each licensee shall furnish to the licensing agency such reports as the Department may require, including, but not limited to, the following: (1) A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence of any of the events specified...This requirement was not met as evidenced by:	1 2 3 4 5 6 7	Administrator has agreed to review Title 22 Reporting Requirements with Care Director and send LPA written notice of review of Title 22 Reporting Requirements. This is due to LPA by 12/8/2021.
	8 9 10 11 12 13 14	Based on interview and record review, this facility did not maintain compliance as evidenced by there were never any Incident reports sent to Community Care Licensing within seven days. This poses a potential threat to the Health, Safety, and Personal Rights of all residents in care.	8 9 10 11 12 13 14
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

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: Czarrina A Camilon-Lee	TELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Christopher Hopkins-Clarke	TELEPHONE: (916) 263-4700
LICENSING EVALUATOR SIGNATURE:	DATE: 12/01/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/01/2021

LIC9099 (FAS) - (06/04)

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