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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 347005426
Report Date: 12/08/2022
Date Signed: 12/08/2022 05:12:41 PM


Document Has Been Signed on 12/08/2022 05:12 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: DATE:
12/08/2022
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
04:45 PM
MET WITH:Kathleen Gilbey, Administrator TIME COMPLETED:
05:00 PM
NARRATIVE
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Licensing Program Analyst (LPA) Sabrina Calzada arrived unannounced to issue (2) citations related to (2) additional deficiencies discovered when further reviewing complaint documentation during an appeal review for a citation(s) issued on 8/30/22. 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.

Findings were delivered on 4/12/22 to complaint #25-AS-20211027124047, regarding resident (R1). Documentation was further reviewed during an appeal process, and the following (2) deficiencies were found:

Documentation reviewed shows resident (R1) had an initial assessment completed on 8/13/2016 and a care plan completed 9/1/2016. A subsequent periodic assessment was completed on 11/30/2016.

Documentation reviewed did not show that a reappraisal was completed following the first incident of R1 becoming highly intoxicated on 11/13/2017. Additionally, resident's care plan was not found to have been updated following the same incident. Resident's care plan was not updated again until 7/14/2018,following the second incident of R1 becoming highly intoxicated on 7/13/2018.

Per California Code of Regulations, Title 22, Chapter 6, Division 8 the following (2) deficiencies are being issued on the 809D page.

Exit interview. Copy of report and appeal rights provided.
SUPERVISOR'S NAME: Maribeth SentyTELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Sabrina CalzadaTELEPHONE: (510) 829-2133
LICENSING EVALUATOR SIGNATURE:
DATE: 12/08/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/08/2022
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 12/08/2022 05:12 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: 12/08/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
12/22/2022
Section Cited

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87463 Reappraisals. (a) The pre-admission appraisal shall be updated, in writing as frequently as necessary to note significant changes and to keep the appraisal accurate. The reappraisals shall document changes in the resident's physical, medical, mental, and social condition. Significant changes shall include but not be limited to: (3) Any illness, injury, trauma, or change in the health care needs of the resident that results in a circumstance or condition specified in Sections 87455(c) or 87615, Prohibited Health Conditions.
This requirement is not met as evidencd by:
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Based on documentation review, the Licensee did not ensure that a reappraisal was completed, on/around 11/13/2017 when R1 became highly intoxicated, to document the change in resident (R1) care needs, which posed a potential health and safety risk to residents in care.
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Type B
12/22/2022
Section Cited

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87467 Resident Participation in Decisionmaking. (a) Prior to, or within two weeks of the resident’s admission, the licensee shall arrange a meeting with the resident, the resident’s representative, if any, appropriate facility staff, and a representative of the resident’s home health agency, if any, and any other appropriate parties, to prepare a written record of the care the resident will receive in the facility, and the resident’s preferences regarding the services provided at the facility. (3) The licensee shall arrange a meeting with the resident and appropriate individuals identified in Section 87467(a)(1) to review and revise the written record as specified, when there is a significant change in the resident’s condition, or once every 12 months, whichever occurs first. Significant changes shall include, but not be limited to occurrences specified in Section 87463, Reappraisals.
This requirement is not met as evidenced by:
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Based on documentation reviewed, the Licensee did not ensure that resident's (R1) care plan was updated to reflect additional care/supervision needed, following resident being highly intoxicated on 11/13/2017, which posed a potential health and safety 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: Maribeth SentyTELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Sabrina CalzadaTELEPHONE: (510) 829-2133
LICENSING EVALUATOR SIGNATURE:
DATE: 12/08/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/08/2022
LIC809 (FAS) - (06/04)
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