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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 342701121
Report Date: 03/20/2024
Date Signed: 03/20/2024 04:35:22 PM

Substantiated


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
09/21/2023 and conducted by Evaluator Kevin Gould
COMPLAINT CONTROL NUMBER: 27-AS-20230921115438
FACILITY NAME:OAKMONT OF EAST SACRAMENTOFACILITY NUMBER:
342701121
ADMINISTRATOR:LUIS OLIVASFACILITY TYPE:
740
ADDRESS:5301 F STREETTELEPHONE:
(916) 905-2400
CITY:EAST SACRAMENTOSTATE: CAZIP CODE:
95819
CAPACITY:214CENSUS: 136DATE:
03/20/2024
UNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Kathleen GilbyTIME COMPLETED:
05:00 PM
ALLEGATION(S):
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1) Neglect/Lack of Supervision: Resident sustained a fracture due to lack of care from staff
2) Other: Facility call system is in disrepair
3) Reporting Requirements: Staff did not inform resident's authorized person of resident's hospitalization
INVESTIGATION FINDINGS:
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Licensing Program Analysts (LPA) Kevin Gould made an announced inspection to the Oakmont of East Sacramento RCFE on 3/20/24 at 9:00am to conclude the investigation of the above allegations and to deliver the findings. LPA Gould met with Administrator, Kathleen Gilby and together discussed the investigation details.

Based on the interviews and statements obtained during the investigation process, the allegations are determined to be substantiated. Regarding allegations that resident sustained an injury due to lack of care from staff, the Department conducted interviews with seven staff members and S1, S3, S5 and S7 (See confidential name list LIC-811 dated 3/20/24) all provided statements to the department that R1 being a fall risk and having multiple falls while at the facility. A1 and A2 statements revealed that the facility failed to provide R1 with a fall prevention plan. A2 provided several emails to S2 and S3 regarding R1's alert pendant not working properly and concerns to address R1's falls prior to most recent fall.
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Czarrina A Camilon-LeeTELEPHONE: (916) 214-5136
LICENSING EVALUATOR NAME: Kevin GouldTELEPHONE: (619) 672-5924
LICENSING EVALUATOR SIGNATURE:

DATE: 03/20/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/20/2024
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 4
Control Number 27-AS-20230921115438
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: 03/20/2024
NARRATIVE
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Interviews with staff including S3, S1, S5 and S7 revealed consistent statements of R1's decline in her ability to be stable and walk. S1, S5 and S7 detailed that R1 had three to four falls that occurred within the last six months of R1 living at the facility. S3, S1, S5 and S7 denied knowing about a fall prevention plan for R1. All of the staff agreed that the alert pendants were not reliable and do not always work.

Additionally, regarding reporting requirements, A2 and A1 both provided statements to the department they were not contacted regarding R1's latest fall and hospitalization. These statements have been corroborated by R2 who provided statements that A2 was not aware of R1's fall and hospitalization or absence from the facility. Staff interviews were unable to corroborate a staff actually contacted an emergency contact and the facility was unable to provide any evidence of contact with emergency contacts.

The Department has determined, based on the preponderance of the evidence obtained during this investigation, that the allegation of Neglect/Lack of Supervision, Reporting requirements and Other is substantiated.

The following deficiencies are cited per California Code of Regulations, TITLE 22. Due to the identified violation resulting in a resident injury an immediate civil penalty is issued and the department will evaluate the circumstances of the violation for additional civil penalties.

Exit interview was conducted with facility staff. Appeal Rights were issued, and a copy of this report was left at the facility.
SUPERVISOR'S NAME: Czarrina A Camilon-LeeTELEPHONE: (916) 214-5136
LICENSING EVALUATOR NAME: Kevin GouldTELEPHONE: (619) 672-5924
LICENSING EVALUATOR SIGNATURE:

DATE: 03/20/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/20/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 4
Control Number 27-AS-20230921115438
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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/20/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Deficiency Dismissed
Type A
03/21/2024
Section Cited
CCR
87465(a)(1)
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Incidental Medical and Dental Care: The licensee shall arrange, or assist in arranging, for medical and dental care appropriate to the conditions and needs of residents. This requirement was not met as evidenced by staff statements that they were aware of R1's decline in mobility but did not have a fall
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Facility will submit an updated fall risk/prevention plan to the facility for approval and when approved will become part of the facility plan of operation. facility will also conduct training on communication, implementation and oversight of fall risk program by the POC due date 3/21/24.
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prevention plan in placement to address recurring falls which resulted in additional falls where R1 sustained a fracture which required hospitalization which poses an immediate health, safety and personal rights risk to residents in care.
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Request Denied
Type A
03/21/2024
Section Cited
CCR
87468.1(a)(8)
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Personal Rights of Residents in All Facilities: To have their representatives regularly informed by the licensee of activities related to care or services, including ongoing evaluations, as appropriate to their needs. this requirement was not met as evidenced by
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Facility will provide and updated written plan of correction identifying the policies and procedures for notifying authorized representatives of incidents at the facility and will conduct appropriate training for staff to ensure reporting requirements are met.
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 statements from A1, A2 and R2 who corroborated statements that authorized representatives were not notified by facility staff of R1's fall and subsequent hospitalization which poses an immediate health, safety and personal rights risk for 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: Czarrina A Camilon-LeeTELEPHONE: (916) 214-5136
LICENSING EVALUATOR NAME: Kevin GouldTELEPHONE: (619) 672-5924
LICENSING EVALUATOR SIGNATURE:

DATE: 03/20/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/20/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 4
Control Number 27-AS-20230921115438
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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/20/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Request Denied
Type A
03/21/2024
Section Cited
CCR
87303(i)(1)(A)
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Maintenance and Operation: Facilities shall have signal systems which shall meet the following criteria: Operate from each resident's living unit. This requirement was not met as evidenced by statements obtained from A1, A2, S1, S5, S3, and S7 that state they do not
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Facility will submit a written plan of correction indicating the steps the facility takes to ensure regular testing of resident pendents and staff pagers to ensure they are operating as intended and staff receive notifications for assistance.
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believe the call system operates properly and there are times where they are not notified of an alert from a resident's room and documented concerns of call system not working as designed which poses an immediate 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: Czarrina A Camilon-LeeTELEPHONE: (916) 214-5136
LICENSING EVALUATOR NAME: Kevin GouldTELEPHONE: (619) 672-5924
LICENSING EVALUATOR SIGNATURE:

DATE: 03/20/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/20/2024
LIC9099 (FAS) - (06/04)
Page: 4 of 4