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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342701121
Report Date: 07/23/2024
Date Signed: 07/24/2024 10:04:44 AM

Document Has Been Signed on 07/24/2024 10:04 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		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 SACRAMENTOFACILITY NUMBER:
342701121
ADMINISTRATOR/
DIRECTOR:		KATHLEEN GILBEYFACILITY TYPE:
740
ADDRESS:5301 F STREETTELEPHONE:
(916) 905-2400
CITY:EAST SACRAMENTOSTATE: CAZIP CODE:
95819
CAPACITY: 214TOTAL ENROLLED CHILDREN: 0CENSUS: 135DATE:
07/23/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
03:00 PM
MET WITH:Kathleen Gilbey TIME VISIT/
INSPECTION COMPLETED:
03:30 PM
NARRATIVE
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On 07/23/2024, Licensing Program Analysts (LPAs) Arielle Pascua and Pang Lee arrived unannounced to conduct a case management visit. LPAs met with Facility Designated Administrator (FDA), Kathleen Gilbey and explained the purpose of the visit.
The purpose of this visit was to follow up on an incident report received by the department on 06/29/2024.

On 06/23/2024, the department received an LIC 624 incident report that occurred on 06/23/2024 regarding resident 1 (R1). LPA reviewed the incident report, and it was learned that on 06/23/2024, during an internal community medication audit, it was noted that (R1)’s Megestrol Acetate 40 mg with directions of take 2 tablets by mouth 2 times daily for 3 weeks was not given to resident from 06/03/2024 to 06/06/2024, 06/12/2024 to 06/20/2024 for a total of 12 days.

Furthermore, the incident report dated on 06/29/2024 states that R1 was diagnosed by a home health nurse that they have an unstageable wound on 06/20/2024 at 5:30pm and sent to UC Davis hospital for further evaluation on 06/21/2024.


Based on record review, this incident report was faxed to the department on 06/29/2024, however the incident occurred on 06/20/2024 and 06/21/2024. As a result, the facility did not follow the reporting requirements.

LPA obtained facility records. Due to insufficient time to review documentation and conduct interviews the department will come at a later date to follow up on the incident reported on 06/29/2024.

The following deficiencies were observed and cited from the California Code of Regulations, Title 22, and California Health and Safety Code. The deficiencies can be found on the 809-D page.

An exit was interview conducted, and a copy of the 809 report, 809-D page, and appeal rights were given to the facility.
Lisa RiosTELEPHONE: (916) 969-9685
Arielle PascuaTELEPHONE: (916) 862-5907
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.

LIC809 (FAS) - (06/04)
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Document Has Been Signed on 07/24/2024 10:04 AM - 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
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: 07/23/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Deficiency Dismissed
Type B
08/23/2024
Section Cited
CCR
87211(a)(1)

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(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 in (A) through (D) below. This report shall include the resident's name, age, sex and date of admission; date and nature of event; attending physician's name, findings, and treatment, if any; and disposition of the case.
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Licensee shall provide a statement of correction and acknowledgement, along with proof of staff training for no less than (1) hour in duration, for the cited section will be completed and submitted to the LPA's email at arielle.pascua@dss.ca.gov
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This is not met as evidenced by: Based on record review and interview the facility did not report R1's unstageable wound within 7 days of occurence. The incident occured on 06/20/2024 and 06/21/2024 and the facility did not provide the incident report to the department until 06/29/2024. This poses a potential health, safety, and personal rights risks to persons in care.
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by the due date od 08/23/2024 COB at 5:00pm. Information submitted must include attendees, trainers, and information discussed.

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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.
Lisa RiosTELEPHONE: (916) 969-9685
Arielle PascuaTELEPHONE: (916) 862-5907

DATE: 07/23/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/23/2024

LIC809 (FAS) - (06/04)
Page: 2 of 3


Document Has Been Signed on 07/24/2024 10:04 AM - 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
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: 07/23/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Request Denied
Type A
07/24/2024
Section Cited
CCR
87465(a)(4)

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87465 Incidental Medical and Dental Care
(a) A plan for incidental medical and dental care shall be developed by each facility. The plan shall encourage routine medical and dental care and provide for assistance in obtaining such care, by compliance with the following:
(4) The licensee shall assist residents with self-administered medications as needed.
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Licensee shall provide a statement of correction and acknowledgement, along with proof of staff training for no less than (1) hour in duration, for the cited section will be completed and submitted to the LPA's email at arielle.pascua@dss.ca.gov
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This was not met as evidenced by: Based on record review and interview the Licensee did not ensure that (R1) received (R1) medications as prescribed by (R1)’s physician’s order. The facility did not provide the residents medication prescribed by the doctor from 06/03/2024 to 06/06/2024 and again from 06/12/2024-06/20/2024. This poses an immediate health, safety, and personal rigths risks to persons in care.

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by the due date of 08/24/2024 COB at 5:00pm. Information submitted must include attendees, trainers, and information discussed.

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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.
Lisa RiosTELEPHONE: (916) 969-9685
Arielle PascuaTELEPHONE: (916) 862-5907

DATE: 07/23/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/23/2024

LIC809 (FAS) - (06/04)
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