347005426-12-8-2022-25-AS-MSEY-CDFRZB-20220413132739

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 347005426
Report Date: 04/12/2022
Date Signed: 12/08/2022 05:17:17 PM

Substantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 520 COHASSET RD., STE. 170
CHICO, CA 95926

This is an official report of an unannounced visit/investigation of a complaint received in our office on
10/27/2021 and conducted by Evaluator Sabrina Calzada

PUBLIC

COMPLAINT CONTROL NUMBER: 25-AS-20211027124047

FACILITY NAME:	OAKMONT OF CARMICHAEL		FACILITY NUMBER:	347005426
ADMINISTRATOR:	NATHAN CONDIE		FACILITY TYPE:	740
ADDRESS:	4717 ENGLE RD		TELEPHONE:	(916) 483-3800
CITY:	CARMICHAEL	STATE: CA	ZIP CODE:	95608
CAPACITY:	0	CENSUS: 71	DATE:	04/12/2022
		UNANNOUNCED	TIME BEGAN:	11:30 AM
MET WITH:	Kathleen Gilbey, Executive Director/Administrator		TIME COMPLETED:	06:20 PM

ALLEGATION(S):

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Staff did not adhere to physician orders regarding a resident
Staff did not protect a resident from alcohol poisoning
Staff did not provide adequate supervision to residents
Facility had inadequate record keeping regarding a resident

INVESTIGATION FINDINGS:

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**This report is being amended on 12/8/2022 to re-assess a civil penalty that was incorrectly issued on a separate 809 report on 8/30/2022. The 9099D page has been updated to note that a paper LIC421IM is being issued to re-issue a $500 civil penalty. There are no other changes made to this report. **

Licensing Program Analyst (LPA) Sabrina Calzada arrived unannounced to deliver findings to a complaint received on 10/27/2021. LPA was screened upon entering the facility by concierge and was informed Administrator was currently in a meeting. Prior to initiating today's inspection, LPA completed required COVID-19 testing protocols, and a daily self-screening questionnaire for symptoms of COVID-19 infection to affirm no COVID-19 related symptoms;. LPA ensured she applied hand sanitizer before entering the facility and the following Personal Protective Equipment (PPE) was worn: KN95 mask. LPA later met with Kathleen Gilby, Administrator, and explained purpose of inspection.

During the investigation, LPA interviewed the current Administrator, Resident Care Coordinator (worked as Med-Tech previously), Memory Care Director and Activity Director. Additionally, LPA interviewed (3) caregivers, (1) Med-Tech and (1) staff who worked as an Assistant Activity Director and resident's responsible person. LPA was unable to interview an additional (3) staff, the prior Administrator and Health Services Director due to them no longer being employed at the facility. Resident resided exclusively in the Assisted Living Unit of the facility for the duration of the time as a resident, even though resident had a diagnosis of Dementia.

cont on 9099C(1)...

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Maribeth Senty	TELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Sabrina Calzada	TELEPHONE: (510) 829-2133
LICENSING EVALUATOR SIGNATURE:	DATE: 04/12/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/12/2022

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 8

Control Number 25-AS-20211027124047

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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
	VISIT DATE: 04/12/2022

NARRATIVE

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9099C(1)...LPA reviewed the following documentation pertaining to resident (R1), including but not limited to: Resident Information Sheet, physician's written order, Physician's Reports, Unusual incident/injury report (LIC624), retail store receipt, hospital medical records, Resident Handbook and other documentation.

Allegation: Staff did not adhere to physician orders regarding a resident.

Unusual incident/injury report (LIC624) submitted to the Department on 11/13/2017 notes that on 11/13/2017, "resident (R1) was consuming alcohol, became intoxicated, with aggressive behaviors" and 911 was called and resident was sent out to the emergency room. The LIC624 notes that resident returned to the facility in the morning and facility staff would be "monitoring alcohol use" of the resident and who will see the doctor this week. Hospital Medical records document that resident arrived at the emergency room via ambulance on 11/13/2017 at 8:45 pm with a principal diagnosis of "alcohol abuse with intoxication, uncomplicated" and was discharged on 11/14/2017 at 10:57 am. Hospital medical records indicate that resident's Blood Alcohol Concentration (BAC) level was 301 mg on 11/13/2017 upon admission. Nurse notes entered on 11/13/2017 at 2059 note "patient is alert to self only, patient smells of ETOH, from assisted living facility, per staff, patient usually drinks and has memory problems but is increasingly combative tonight and altered".

Following the incident on 11/13/2017, resident's physician sent a signed order to the facility on 11/15/2017 stating "(R1) has a significant alcohol abuse issue which will worsen his brain function and memory. Patient cannot drink alcohol at the facility and please make sure patient does not buy or store alcohol at the facility from the outside".

Multiple interviews revealed that staff were aware that resident could not have alcohol in their room or drink it due to resident's doctor not allowing it and resident's behavior becoming more aggressive. Several staff indicated that resident was served non-alcoholic drinks during events held at the facility and if resident smelled of alcohol, they would be required to immediately report it to the Med-Tech on duty .

The Activity Director stated in March 2022 that the facility has regular scheduled outings to retail food stores that sell alcohol, including in 2018, and indicated that if the resident is an Assisted Living resident, then it is "their right to buy what they want and we can't stop him from purchasing something- it's for their dignity", adding staff "might not see everything a resident would purchase at the store". The Activity Director further stated that she would let the pertinent people know if she saw a resident purchase something that he/she is not supposed to have, if she saw it, explaining that she "walks around the store" and offers to help residents. In addition, the Activity Director stated that Med-Techs will check a resident's room if he/she was not supposed to have something, and confirmed she trains staff to do this.

cont on 9099C(2)...

SUPERVISOR'S NAME: Maribeth Senty	TELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Sabrina Calzada	TELEPHONE: (510) 829-2133
LICENSING EVALUATOR SIGNATURE:	DATE: 04/12/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/12/2022

LIC9099 (FAS) - (06/04)

Page: 2 of 8

Control Number 25-AS-20211027124047

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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
	VISIT DATE: 04/12/2022

NARRATIVE

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9099C(2)...Resident's responsible person (RP) stated she was called by the facility Health Services Director (HSD) on 7/13/2018, at approximately 12:00 pm, to inform her that resident had been sent out to the emergency room due to excessive alcohol consumption. RP stated she had a meeting with resident and the HSD later that day to discuss how resident obtained the alcohol to become intoxicated. RP stated that once the meeting had concluded in resident's room, she checked resident's refrigerator and found (2) bottles of vodka, one of which had been opened and was half empty, as well as a receipt from a local retail store, dated 7/13/2018 showing that (2) bottles of vodka were purchased at 10:22 am, using a credit card. RP indicated that she confirmed with the HSD on 7/13/2018, that there had been a supervised excursion to the same grocery store earlier that morning and several residents had attended. RP confirmed that the credit card used to purchase the (2) bottles of vodka on 7/13/2018 belonged to resident, based on the last 4 digits shown on the receipt.

Hospital medical records document that on 7/13/2018, resident was sent out to the emergency room and arrived at 1:27 pm. with a primary diagnosis of "alcohol use, unspecified with intoxication, uncomplicated" and "Alzheimer's Disease with early onset". Hospital medical records document that resident's Blood Alcohol Concentration (BAC) level was 259 mg on 7/13/2018 upon admission and resident had a "toxic ingestion" and was discharged on 7/13/2018, at approximately 06:40 pm, back to the facility. A LIC624 was not found to have been submitted to the Department following the incident, and a copy was not provided when requested by the LPA during the investigation.

Physician’s report dated 8/3/2017 documents that resident has a primary diagnosis of Alzheimer’s Dementia, a secondary diagnosis of hypertension and is only able to leave the facility with supervision. Resident Information Sheet dated 6/17/2018 states that resident wears a Roam Alert Safety Bracelet, is unable to leave the community unassisted and cannot drink alcohol at the community.

One staff who was interviewed and went on many excursions with resident, stated "(R1) would wander a lot" but they would always check on resident, stating R1 " tried to buy alcohol a few times. I told him the Dr. won't allow it because of the medications he was taking. He was okay with it. " When asked if residents can purchase alcohol during a facility excursion, the staff stated, "We are not supposed to say "no" unless there is a doctor's note" and if we find something that is not allowed when we check the bags, the Med-Tech would take it - "I would check bags, but I never saw resident (R1)with alcohol".
cont on 9099C(3)...

SUPERVISOR'S NAME: Maribeth Senty	TELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Sabrina Calzada	TELEPHONE: (510) 829-2133
LICENSING EVALUATOR SIGNATURE:	DATE: 04/12/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/12/2022

LIC9099 (FAS) - (06/04)

Page: 3 of 8

Control Number 25-AS-20211027124047

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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
	VISIT DATE: 04/12/2022

NARRATIVE

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9099C(3)..This staff stated they regularly worked from Tuesday through Saturday and was working in July 2018 and stated "He (R1) didn't know how to pay, using a debit or credit card, and adding a tip, so I would help him”. Based on calendar review, July 13, 2018 was a Friday.

RP stated that due to resident's diagnosis of Dementia, resident needed assistance with using a credit or debit card as resident had difficulty remembering the Personal Identification Number (PIN) and also did not know the difference between credit and debit.

Based on information obtained from interviews and documentation, LPA finds the allegation to be SUBSTANTIATED- A finding that the complaint is Substantiated means that the allegation is valid because the preponderance of the evidence standard has been met.

Allegation: Staff did not protect a resident from alcohol poisoning.

Review of a retail store receipt found in resident's room on 7/13/2018, shows that (2) bottles of Tahoe Blue Vodka were purchased, along with 2 bottles of water and blueberries at 10:22 am. Responsible person confirmed that resident went on a facility excursion on the morning of 7/13/2018 to a local supermarket that sold alcohol. Interviews with multiple staff revealed that all staff knew that resident wasn't allowed any alcohol. Responsible person stated during the investigation that she found (2) bottles of the same brand of alcohol purchased on the receipt in the refrigerator in resident's room later on the same day following the excursion, and (1) bottle had been opened and was half empty.

The Activity Director stated "it was known he had an issue with alcohol" and she would let the pertinent people know if she saw a resident purchase something that he/she is not supposed to have, if she saw it, explaining that she "walks around the store" and offers to help residents while they shop. In addition, the Activity Director stated that Med-Techs will check a resident's room if he/she was not supposed to have something and she trains staff to do this. A staff who regularly accompanied resident on outings stated that staff are not supposed to say "no" unless there is a doctor's note" and if we find something that is not allowed when we check the bags, and the Med-Tech would take it, adding, "I would check bags, but I didn't take it" and clarified that he "never saw resident with alcohol", and "with me (R1) would listen if I told him no".

cont on 9099C(4)..

SUPERVISOR'S NAME: Maribeth Senty	TELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Sabrina Calzada	TELEPHONE: (510) 829-2133
LICENSING EVALUATOR SIGNATURE:	DATE: 04/12/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/12/2022

LIC9099 (FAS) - (06/04)

Page: 4 of 8

Control Number 25-AS-20211027124047

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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
	VISIT DATE: 04/12/2022

NARRATIVE

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9099C(4).. Resident was sent out to the emergency room on 7/13/2018 and arrived at 1:27 pm. Resident was not provided the adequate care and supervision during and following the purchase of the alcohol at 10:22 am, as resident was able to drink approximately half of one bottle of vodka, prior to arriving at the emergency room at 1:27 pm with a BAC level of 259 mg.

Resident Handbook states the facility policy for alcohol is "You may keep alcohol in your apartment unless medically prohibited by your physician. If your behavior is affected by the amount of alcohol that you consume, as a courtesy to other residents we ask that you utilize your apartment and avoid common areas".

Based on information obtained from interviews and documentation, LPA finds the allegation to be SUBSTANTIATED- A finding that the complaint is Substantiated means that the allegation is valid because the preponderance of the evidence standard has been met.

Allegation: Staff did not provide adequate supervision to residents.

Activity Director stated in January 2022 "We can have 6 residents if none are wearing a wandergaurd. Residents who wear a wanderguard are "mostly ALU" residents. If a resident with a wandergaurd would like to go, we take extra staff. There is a 6:1 ratio if no residents wear a wanderguard. Activity Director confirmed in January 2022 with LPA that staffing records were no longer available prior to September 2018 to confirm how many staff attended an excursion.

A staff who attended many excursions with resident (R1) stated "He (R1) would wander a lot". When more than 5 people (residents) wanted to go, we had to get another staff person and "Sometimes we had 10 residents and 1 staff".

Resident'(R1) Information Sheet, dated 6/17/2018, lists under "Alerts" that 1) resident has a "Roam Alert Safety Bracelet" and 2) is unable to leave the community unassisted and 3) resident cannot drink alcohol at the community. Staff interviews concluded that resident wore a wanderguard bracelet and could not leave the building unattended starting prior to the second incident of intoxication, on 7/13/2018.

cont on 9099C(5)..

SUPERVISOR'S NAME: Maribeth Senty	TELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Sabrina Calzada	TELEPHONE: (510) 829-2133
LICENSING EVALUATOR SIGNATURE:	DATE: 04/12/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/12/2022

LIC9099 (FAS) - (06/04)

Page: 5 of 8

Control Number 25-AS-20211027124047

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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
	VISIT DATE: 04/12/2022

NARRATIVE

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9099C(5).. Administrator stated in March 2022, that currently if a resident wears a "wander guard" bracelet, then resident doesn't usually attend the outing".

Based on information obtained through interviews and documentation, staff did not provide adequate supervision to resident (R1) who was able to purchase (2) bottles of Vodka using resident's credit/debit card on 7/13/2018 and would have required assistance to do so due to being memory impaired because of a diagnosis of Dementia. .

LPA finds the allegation to be SUBSTANTIATED- A finding that the complaint is Substantiated means that the allegation is valid because the preponderance of the evidence standard has been met.

Allegation: Facility had inadequate record keeping regarding a resident. Allegation states that the facility asked resident to sign the Physician's Report dated 7/8/18 when this report should have been signed by the power of attorney also. Resident also signed the prior year's physician report, dated 8/3/2017.

Resident's original LIC602 is signed/dated 7/27/2016 by the physician and notes resident has Mild Cognitive Impairment with "gradual memory loss". Resident's physician's report (LIC602) was updated on 8/3/2017 and notes that resident has a primary diagnosis of Alzheimer's Dementia. LPA reviewed the LIC602, dated 8/3/2017, and observed another copy to have resident's signature, without the responsible person's, with the date of 7/18/2018. Resident's responsible person did not sign this updated copy and stated in an interview that she was not asked to sign it.

Based on information obtained, the facility requested that resident sign and date the prior year's physician report when an updated report from the doctor was required due to resident's Dementia diagnosis.

LPA finds the allegation to be SUBSTANTIATED- A finding that the complaint is Substantiated means that the allegation is valid because the preponderance of the evidence standard has been met.

Per California Code of Regulations, Title 22, Division 6, Chapter 8, the following (4) deficiencies are cited. Exit interview. Copy of report and appeal rights provided to Administrator.

SUPERVISOR'S NAME: Maribeth Senty	TELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Sabrina Calzada	TELEPHONE: (510) 829-2133
LICENSING EVALUATOR SIGNATURE:	DATE: 04/12/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/12/2022

LIC9099 (FAS) - (06/04)

Page: 6 of 8

Control Number 25-AS-20211027124047

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 04/12/2022

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Request Denied Type A 04/14/2022 Section Cited CCR 87705(f)(2)	1 2 3 4 5 6 7	87705 Care of Persons with Dementia (f) The following shall be stored inaccessible to residents with dementia: (2) Over-the-counter medication, nutritional supplements or vitamins, alcohol, cigarettes, and toxic substances such as certain plants, gardening supplies, cleaning supplies and disinfectants. This requirement is not met as evidenced by:	1 2 3 4 5 6 7	Licensee/Administrator agree to review resident Information Sheet with current activity staff and care staff.
	8 9 10 11 12 13 14	Based on interviews and documentation reviewed, the Licensee did not ensure that resident (R1) was prohibited 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, which posed an immediate health and safety risk to residents in care.	8 9 10 11 12 13 14	documentation of staff training/agenda to be provided to department by 4/27/2022.
Request Denied Type A 04/14/2022 Section Cited CCR 87464(d)	1 2 3 4 5 6 7	87464 Basic Services (d) A facility need not accept a particular resident for care. However, if a facility chooses to accept a particular resident for care, the facility shall be responsible for meeting the resident's needs as identified in the pre-admission appraisal specified in Section 87457, Pre-admission Appraisal and providing the other basic services specified below, either directly or through outside resources. This requirement is not met as evidenced by:	1 2 3 4 5 6 7	Licensee/Administrator agree to review resident Information Sheet with current activity staff and care staff and to discuss any restrictions residents have. Documentation of staff training/agenda to be provided to department by 4/27/2022.
	8 9 10 11 12 13 14	Based on interviews and documentation reviewed, the Licensee did not ensure that resident (R1) did not have any access to alcohol during or following the excursion on 7/13/2018 as staff did not follow the alert on resident's Information Sheet regarding no drinking alcohol at the community, which posed an immediate health and safety risk to residents in care.	8 9 10 11 12 13 14	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, 12/8/22, on a paper copy of the LIC421IM. Hospital medical records indicate that resident's Blood Alcohol Concentration (BAC) level was 301 mg on 11/13/2017 upon being admitted.

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 Senty	TELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Sabrina Calzada	TELEPHONE: (510) 829-2133
LICENSING EVALUATOR SIGNATURE:	DATE: 04/12/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/12/2022

LIC9099 (FAS) - (06/04)

Page: 8 of 8

Control Number 25-AS-20211027124047

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 04/12/2022

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Request Denied Type A 04/14/2022 Section Cited CCR 87705(c)(4)	1 2 3 4 5 6 7	87705 Care of Persons with Dementia (c) Licensees who accept and retain residents with dementia shall be responsible for ensuring the following: (4) There is an adequate number of direct care staff to support each resident’s physical, social, emotional, safety and health care needs as identified in his/her current appraisal. This requirement is not met as evidenced by:	1 2 3 4 5 6 7	Licensee/Administrator agree to review regulation with current activity staff, restrict residents with a wanderguard from excursions except when there is appropriate staffing and better supervise the purchases.
	8 9 10 11 12 13 14	Based on interviews conducted and documentation reviewed, the Licensee did not ensure that there was sufficient staffing so that resident (R1) who has a diagnosis of Dementia, was not able to purchase alcohol during a facility excursion on 7/13/2018, become intoxicated and had to be sent to the emergency room, which posed an immediate health and safety risk to residents in care.	8 9 10 11 12 13 14	documentation of staff training/agenda to be provided to department by 4/27/2022.
Request Denied Type B 04/26/2022 Section Cited CCR 87705(c)(5)	1 2 3 4 5 6 7	87705 Care of Persons with Dementia (c) Licensees who accept and retain residents with dementia shall be responsible for ensuring the following: 5) Each resident with dementia shall have an annual medical assessment as specified in Section 87458, Medical Assessment, and a reappraisal done at least annually, both of which shall include a reassessment of the resident’s dementia care needs. This requirement is not met as evidenced by:	1 2 3 4 5 6 7	Licensee/Administrator agree to audit files of residents with dementia diagnosis and schedule an appointment to obtain an updated LIC602 if needed. documentation of audit to be provided to department by 4/27/2022.
	8 9 10 11 12 13 14	Based on interviews and documentation, the Licensee did not ensure that resident (R1), who has a diagnosis of Dementia, obtained an annual updated physician's report that was signed by the doctor and responsible person, on/around August 2018, which posed a potential health and safety risk to residents in care.	8 9 10 11 12 13 14

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 Senty	TELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Sabrina Calzada	TELEPHONE: (510) 829-2133
LICENSING EVALUATOR SIGNATURE:	DATE: 04/12/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/12/2022

LIC9099 (FAS) - (06/04)

Page: 7 of 8