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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 347005427
Report Date: 11/09/2020
Date Signed: 11/09/2020 12:01:48 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
FACILITY NAME:OAKMONT OF FOLSOMFACILITY NUMBER:
347005427
ADMINISTRATOR:ANSARI, POUVAFACILITY TYPE:
740
ADDRESS:1574 CREEKSIDE DRTELEPHONE:
(916) 817-4500
CITY:FOLSOMSTATE: CAZIP CODE:
95630
CAPACITY:88CENSUS: 64DATE:
11/09/2020
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Pouya Ansari (Administrator)TIME COMPLETED:
12:15 PM
NARRATIVE
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Licensing Program Analyst (LPA) Konnor Leitzell contacted Pouya Ansari (Administrator) on 11/6/2020 to deliver the following findings regarding an investigation that was the completed based on a self-reported incident Community Care Licensing Division (CCLD) received from the facility on 7/13/2020.



The facility reported on 07/06/2020, the resident was found outside by a facility staff member. It appeared to the facility the resident fell out of the window because the resident’s screen was ripped. Facility staff guided the resident back into the community and back into their room. Resident was placed on 72-hour safety checks by the facility. On 07/09/2020, the resident complained of pain to their right hip, bruising was noticed by facility staff, and the resident was tender to touch. On both 07/08/2020 and 07/10/2020, the resident requested to go to the hospital due to pain and was denied. On 07/11/2020, resident was still complaining of pain and again requested to go to the hospital and was then sent by facility staff for evaluation by medical professionals.



Based on interviews and document review the facility did not seek timely medical care for resident after sustained an injury, showed change in condition, complained of pain and requested medical transportation and treatment.
SUPERVISOR'S NAME: Troy OrdonezTELEPHONE: (916) 263-4832
LICENSING EVALUATOR NAME: Konnor LeitzellTELEPHONE: (916) 708-9618
LICENSING EVALUATOR SIGNATURE:

DATE: 11/09/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/09/2020
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC809 (FAS) - (06/04)
Page: 1 of 3
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
FACILITY NAME: OAKMONT OF FOLSOM
FACILITY NUMBER: 347005427
VISIT DATE: 11/09/2020
NARRATIVE
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The following deficiencies are cited as a result of the licensee’s actions in this incident:

87466 Observation of the Resident: The licensee shall ensure that residents are regularly observed for changes in physical, mental, emotional and social functioning and that appropriate assistance is provided when such observation reveals unmet needs. When changes such as unusual weight gains or losses or deterioration of mental ability or a physical health condition are observed, the licensee shall ensure that such changes are documented and brought to the attention of the resident's physician and the resident's responsible person, if any. The licensee failed to observe the residents change in condition and seek timely medical care. This posed an immediate health and safety risk to residents in care.

87468.1(a)(16) - Personal Rights of Residents in All Facilities: (a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (16) To receive or reject medical care or other services. The facility failed to do this because the resident requested to go to the hospital two days in a row as well as showed signs of injury and the facility did not send the resident until the second request and showed more signs of injury. This posed a potential health and safety risk to residents in care.

As a result of this visit, the following deficiencies were cited, per Title 22 Regulations, Division 6. The following deficiencies were cited on 809-D, per Title 22 Regulations, Division 6.

As a result of resident’s injury, the violation warrants a civil penalty assessment based on health and safety code 1569.49. At this time, the civil penalty assessment is under review. LPA will return at a future date to assess a civil penalty if warranted.


Exit interview conducted with Pouya Ansari and report provided.

Appeals rights printed.
SUPERVISOR'S NAME: Troy OrdonezTELEPHONE: (916) 263-4832
LICENSING EVALUATOR NAME: Konnor LeitzellTELEPHONE: (916) 708-9618
LICENSING EVALUATOR SIGNATURE:

DATE: 11/09/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/09/2020
LIC809 (FAS) - (06/04)
Page: 2 of 3
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

FACILITY NAME: OAKMONT OF FOLSOM
FACILITY NUMBER: 347005427
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/09/2020
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Request Denied
Type A
11/10/2020
Section Cited

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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 (g) The licensee shall immediately telephone 9-1-1 if an injury or other circumstance has resulted in an imminent threat to a resident’s health including, but not limited to, an apparent life-threatening medical crisis except as specified in Sections 87469(c)(2), (c)(3), or (c)(4).
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Based on interviews and records reviewed, the licensee did not ensure 9-1-1 was immediatly telephoned after resident sustained an injury which resulted in imminent threat to the residents health. Resident was not transported to hospital after sustaining a fall from first floor window to sidewalk.
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Request Denied
Type A
11/10/2020
Section Cited

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87468.1 Personal Rights of Residents in All Facilities (a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (16) To receive or reject medical care or other services.
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Based on interviews and records reviewed, the staff did not ensure resident received medical care requested.
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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: Troy OrdonezTELEPHONE: (916) 263-4832
LICENSING EVALUATOR NAME: Konnor LeitzellTELEPHONE: (916) 708-9618
LICENSING EVALUATOR SIGNATURE:
DATE: 11/09/2020
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/09/2020
LIC809 (FAS) - (06/04)
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