342701121-7-24-2024-27-AS-LRIS-D7MTG7-20240729144238

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 342701121
Report Date: 07/23/2024
Date Signed: 07/24/2024 02:15:09 PM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH 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
04/25/2024 and conducted by Evaluator Arielle Pascua

PUBLIC

COMPLAINT CONTROL NUMBER: 27-AS-20240425082151

FACILITY NAME:	OAKMONT OF EAST SACRAMENTO		FACILITY NUMBER:	342701121
ADMINISTRATOR:	KATHLEEN GILBEY		FACILITY TYPE:	740
ADDRESS:	5301 F STREET		TELEPHONE:	(916) 905-2400
CITY:	EAST SACRAMENTO	STATE: CA	ZIP CODE:	95819
CAPACITY:	214	CENSUS: 135	DATE:	07/23/2024
		UNANNOUNCED	TIME BEGAN:	01:30 PM
MET WITH:	Kathleen Gilbey		TIME COMPLETED:	03:00 PM

ALLEGATION(S):

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Staff are not assisting resident with showers
Staff did not ensure the residents blood glucose testing equipment was working properly
Staff did not ensure residents medication was reordered timely causing the resident to miss medication

INVESTIGATION FINDINGS:

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On 07/23/2024, Licensing Program Analysts (LPAs) Arielle Pascua and Pang Lee arrived unannounced to this facility to conduct a complaint visit. LPAs met with Facility Designated Administrator (FDA), Kathleen Gilbey and explained the purpose of the visit. The purpose of this visit was to deliver complaint findings for the allegations above.
Current census was 135. A brief interview with FDA Gilbey was conducted.

Allegation: Staff are not assisting resident with showers.
It was alleged that the staff are not assisting a resident with showers. During the course of this investigation, this LPA reviewed facility records and conducted staff and resident interviews. Based on facility records, R1 moved into the facility on 06/30/2023. On 06/30/2023, the faciltiy conducted a pre-assessment for R1 that only stated that this resident needed care for a special diabetic diet, fall risk program, and assistance with completion of insurance claim forms. A review of the facilities periodic assessments conducted on 07/06/2023, 07/21/2023, 12/09/2023 and 04/01/2024 did not have any changes to personal care services.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Lisa Rios	TELEPHONE: (916) 969-9685
LICENSING EVALUATOR NAME: Arielle Pascua	TELEPHONE: (916) 862-5907
LICENSING EVALUATOR SIGNATURE:	DATE: 07/23/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/23/2024

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 27-AS-20240425082151

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

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

FACILITY NAME: OAKMONT OF EAST SACRAMENTO	FACILITY NUMBER: 342701121
	VISIT DATE: 07/23/2024

NARRATIVE

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All assessments conducted do not have showering or bathing as care provided to R1. A review with R1's physician report states that R1 is able to bathe, dress, groom, and take care of their own toileting needs. An interview with 9 residents were conducted. 1 out 9 residents state that their significant other needed assistance with their showers but did not receive any help when pressing their call button. 8 out 9 residents state that they receive assistance with their showers and do not have any issues at this time. An interview with 5 staff members were conducted. 1 out 5 staff members do not provide direct care needs. 4 out 5 staff members deny not providing R1 or any other resident with assistance with their shower. 1 out 5 staff members state that based on their knowledge the facility did not provide R1 with any assistance with bathing because R1 would deny showers or would not need any help. Based on the information gathered, it is unclear if the facility did not provide the resident with showering needs.

Allegation: Staff did not ensure the residents blood glucose testing equipment was working properly
It was alleged that staff did not ensure that the resident's blood glucose testing equipment was working properly. During the course of this investigation, this LPA reviewed facility records and conducted staff and resident interviews. Based on interviews conducted it was found that on 04/23/2024, R1 was sent to the hospital due to her high blood glucose levels. R1 admitted that they were unable to read their glucose levels because of their monitor being broken. R1's family member was able to purchase a new monitor, however, was not able to obtain it due to the purchase being delayed. A review R1's assessment and care plan did not have any care needs provided by the facility for diabetic monitoring. In addition, R1's physician report states that this resident is on a special diabetic diet however, is able to manage and administer their own medication. An interview with with 5 staff members were conducted. 1 out 5 staff members do not provide direct care needs. 4 out 5 staff members state that they did not provide this resident with diabetic care and that the resident handled all their medication and diabetic needs. Based on the information gathered, it is unclear if the facility did not ensure that the residents blood glucose testing equipment was working properly.

SUPERVISOR'S NAME: Lisa Rios	TELEPHONE: (916) 969-9685
LICENSING EVALUATOR NAME: Arielle Pascua	TELEPHONE: (916) 862-5907
LICENSING EVALUATOR SIGNATURE:	DATE: 07/23/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/23/2024

LIC9099 (FAS) - (06/04)

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Control Number 27-AS-20240425082151

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

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

FACILITY NAME: OAKMONT OF EAST SACRAMENTO	FACILITY NUMBER: 342701121
	VISIT DATE: 07/23/2024

NARRATIVE

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Allegation: Staff did not ensure residents medication was reordered timely causing the resident to miss medication

It was alleged that staff did not ensure residents medication was reordered timely causing the resident to miss medication. During the course of this investigation, this LPA reviewed facility records and conducted interviews. Based on interviews conducted it was learned that on 04/23/2024, R1 was sent to the hospital due to not taking their diabetic medication. An interview with 4 staff members were conducted. 4 out 4 staff members state that R1 was in charge of their medication based on their assessments and the physicians report obtained during admission. 4 out 5 staff member state that this resident was very independent and had denied help for maintaining their diabetic medication. A review of the residents personal care services state that this resident did not have any care needs from the facility regarding medication and notes state that the resident is able to self-manage medication and self medication assessment was completed by the facility. It was agreed that the resident was to provide the facility with a copy of their signed physician medication orders for emergencies. A review of the resident's physician report confirmed that this resident was able to administer, store, and perform their own glucose testing. Based on the information gathered, it is unclear that the staff did not ensure residents medication was reordered timely causing the resident to miss medication.

As a result of this investigation, this Department found the allegations to be UNSUBSTANTIATED. A complaint allegation finding of Unsubstantiated meant that although the allegations may have happened or was valid, there was not a preponderance of the evidence to prove that the alleged violation occurred.

An exit interview was conducted and a copy of this report was provided to the facility at the end of this visit.

SUPERVISOR'S NAME: Lisa Rios	TELEPHONE: (916) 969-9685
LICENSING EVALUATOR NAME: Arielle Pascua	TELEPHONE: (916) 862-5907
LICENSING EVALUATOR SIGNATURE:	DATE: 07/23/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/23/2024

LIC9099 (FAS) - (06/04)

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