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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 347005426
Report Date: 08/30/2022
Date Signed: 08/30/2022 03:51:46 PM


Document Has Been Signed on 08/30/2022 03:51 PM - It Cannot Be Edited

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:0CENSUS: 74DATE:
08/30/2022
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
03:30 PM
MET WITH:Katheen Gilbey, Administrator TIME COMPLETED:
04:00 PM
NARRATIVE
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Licensing Program Analyst (LPA) Sabrina Calzada arrived unannounced to issue a related deficiency to complaint findings issued on April 12, 2022. LPA met with Administrator, Kathleen Gilbey, and explained purpose of inspection. Prior to initiating today's inspection, LPA completed required COVID-19 testing protocols and completed a daily self-screening questionnaire for symptoms of COVID-19 infection to affirm no COVID-19 related symptoms. Additionally, LPA was screened per Covid-19 precautionary measures upon entering the community. LPA ensured she applied hand sanitizer before entering the facility and the following Personal Protective Equipment (PPE) was worn: surgical mask.

On April 12, 2022, the Department concluded a complaint investigation(#25-AS-20211027124047) which substantiated the allegations that 1) Staff did not adhere to physician orders regarding a resident; 2) Staff did not protect a resident from alcohol poisoning and 3) Staff did not provide adequate supervision to residents.

The Department further reviewed the findings and supporting documentation, including hospital medical records and a letter written by resident's (R1) physician on/around November 2017, following the first incident of resident purchasing and consuming a large amount of alcohol leading to alcohol poisoning. Resident's updated care plan and emergency information sheet both also documented, prior to the second incident of alcohol intoxication occurring in July 2018, that resident could not leave the facility unassisted and purchase or consume alcohol, On July 13, 2018, staff took resident to the store during an outing where resident purchased (2) bottles of vodka and were negligent in allowing resident to purchase and consume alcohol resulting in a second incident of alcohol poisoning.

The Department has determined that based on documentation reviewed, there is sufficient evidence to issue a $500 civil penalty to the facility pursuant to Health and Safety Code section 1569.49(c)(1) - a violation that resulted in the injury or illness of a resident.

Today, 8/30/2022, the Department is issuing a Civil Penalty in the amount of $500.

Exit interview was conducted with Administrator. A copy of this report and appeal rights were provided. The Administrator’s signature on these forms acknowledges receipt of these documents.
SUPERVISOR'S NAME: Maribeth SentyTELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Sabrina CalzadaTELEPHONE: (510) 829-2133
LICENSING EVALUATOR SIGNATURE:
DATE: 08/30/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/30/2022
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 08/30/2022 03:51 PM - 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
CCLD Regional Office, 520 COHASSET RD., STE. 170
CHICO, CA 95926


FACILITY NAME: OAKMONT OF CARMICHAEL
FACILITY NUMBER: 347005426

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/30/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
09/02/2022
Section Cited

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§1569.49 Civil penalties; regulations setting forth appeal procedures for deficiencies. (c) The department shall assess an immediate civil penalty of five hundred dollars ($500) per violation and one hundred dollars ($100) for each day the violation continues after citation for any of the following serious violations:

(1) Any violation that the department determines resulted in the injury or illness of a resident. This requirement is not met as evidenced by:
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Based on documentation reviewed, the Licensee did not ensure that resident (R1) was prevented from buying, storing and drinking alcohol at the facility on 7/13/2018 from 10:22 am to 1:27 pm when resident was admited to the emergency room for alcohol intoxication, and a BAC level of 259 mg, which posed an immediate health and safety risk to resident in care.
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Due to the incident on 7/13/2018 being a second incident of resident being highly intoxicated, a CIVIL PENALTY in the amount of $500.00 is being assessed today.

Hospital medical records indicate that resident's Blood Alcohol Concentration (BAC) level was 301 mg on 11/13/2017 upon being admitted.

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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: Maribeth SentyTELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Sabrina CalzadaTELEPHONE: (510) 829-2133
LICENSING EVALUATOR SIGNATURE:
DATE: 08/30/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/30/2022
LIC809 (FAS) - (06/04)
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