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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 347005426
Report Date: 05/10/2021
Date Signed: 05/10/2021 03:30:23 PM

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:
347005426
ADMINISTRATOR:NATHAN CONDIEFACILITY TYPE:
740
ADDRESS:4717 ENGLE RDTELEPHONE:
(916) 483-3800
CITY:CARMICHAELSTATE: CAZIP CODE:
95608
CAPACITY:101CENSUS: 64DATE:
05/10/2021
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
03:25 PM
MET WITH:Kathleen Gilbey, Executive Director TIME COMPLETED:
03:35 PM
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Licensing Program Analyst (LPA) contacted the facility via telephone on 5/10/2021 to deliver findings to an assignment conducted by the department's Investigative Bureau (IB) for an incident occurring on 3/8/2021. LPA spoke with Kathleen Gilbey, Executive Director, and explained purpose of phone call. Findings are being delivered via telephone due to current Covid-19 precautionary measures in place.

The incident occurring on 3/8/2021 involved resident (R1) who, prior to entering the elevator at approximately 5:45 pm after leaving the dining room, fell back, hitting her head and back. The incident was observed by both Resident Care Coordinators as they were nearby the elevator.

Multiple documents were reviewed by the department during the investigation. Resident's physician's report and care plan indicated that resident could walk to all activities and dining on her own with the assistance of a cane or walker. Facility provided resident with a pendant to use to request assistance, if needed. Records reviewed determined that resident did not use the pendant when leaving the dining room just prior to the incident and did not use the facility's "escort service" either before getting up from the dining room table.

Interviews with Resident Care Coordinator and caregiver assigned to resident on 3/8/2021 indicated that resident had not fallen previously since 2019 and would commonly walk to and from the dining room without requesting assistance and was using a walker when the incident occurred. Resident returned to the facility on hospice on 3/11/2021 and passed on 3/22/2021. Based on information obtained and evaluated during the investigation, it could not be established that the resident fell due to a lack of care and supervision by facility staff.

There are no deficiencies being cited in this report.

Exit interview. Copy of report to be e-mailed to Administrator, who agrees to print, sign and return a copy to the department by end of today, 5/10/2021.
SUPERVISOR'S NAME: Maribeth SentyTELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Sabrina CalzadaTELEPHONE: (510) 829-2133
LICENSING EVALUATOR SIGNATURE:

DATE: 05/10/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/10/2021
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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