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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 392700339
Report Date: 08/31/2021
Date Signed: 09/01/2021 10:52:42 AM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
This is an official report of an unannounced visit/investigation of a complaint received in our office on
07/27/2021 and conducted by Evaluator Albert Johnson
PUBLIC
COMPLAINT CONTROL NUMBER: 27-AS-20210727115713
FACILITY NAME:OAKMONT OF BROOKSIDEFACILITY NUMBER:
392700339
ADMINISTRATOR:HOLGUIN, PATRICIA (PATTY)FACILITY TYPE:
740
ADDRESS:3318 BROOKSIDE RDTELEPHONE:
(949) 744-5200
CITY:STOCKTONSTATE: CAZIP CODE:
95219
CAPACITY:0CENSUS: 0DATE:
08/31/2021
UNANNOUNCEDTIME BEGAN:
12:37 PM
MET WITH:P HolguinTIME COMPLETED:
02:30 PM
ALLEGATION(S):
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Resident was locked out of their room
INVESTIGATION FINDINGS:
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Licensing Program Analyst Albert Johnson arrived to deliver findings for the complaint investigation. LPA discussed the purpose of the visit and the allegation(s) with Ms. Holguin.

Based on records reviewed and interviews conducted the facility did lock R1's room. The facility locked the residents rooms to keep other residents from wandering into other residents' room which lead to aggressive act between the residents. During the course of the investigation it was discovered that the facility had a virtual meeting with the family of R1 and as a result of the meeting the parties agreed to have the residents rooms open to allow for R1 to have access to the restroom and to have the opportunity to lay down if R1 needs the rest.

Continued
Substantiated
Estimated Days of Completion: 0
SUPERVISORS NAME: Stephenie Doub
LICENSING EVALUATOR NAME: Albert Johnson
LICENSING EVALUATOR SIGNATURE:

DATE: 08/31/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/31/2021
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 3
Control Number 27-AS-20210727115713
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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 BROOKSIDE
FACILITY NUMBER: 392700339
VISIT DATE: 08/31/2021
NARRATIVE
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The facility has scheduled a meeting to update the service plan to include the information discussed in the meeting from 8/17/2021.

Based on LPA's interviews, observation and records reviewed, the preponderance of evidence standard has been met, therefore the above allegation is found to be substantiated.

The following deficiency was observed (see LIC 9099-D) and cited from the California Code of Regulations, Title 22. Failure to correct the deficiency may result in civil penalties. Appeal rights were provided. Exit interview conducted and a copy of this report was provided.
SUPERVISORS NAME: Stephenie Doub
LICENSING EVALUATOR NAME: Albert Johnson
LICENSING EVALUATOR SIGNATURE:

DATE: 08/31/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/31/2021
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 27-AS-20210727115713
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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 BROOKSIDE
FACILITY NUMBER: 392700339
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/31/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Request Denied
Type B
09/01/2021
Section Cited
CCR
87705(I)(5)
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87705 Care of Persons with Dementia (5) Interior and exterior space shall be available on the facility premises to permit residents with dementia to wander freely and safely.
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The facility has addressed the situation with the family and has developed a plan to meet the need of R1 without locking the room. The facility held a meeting on 8/17/2021
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This requirement was not met as evidenced by records reviewed and interviews conducted. The facility locked R1's room and as a result R1 went into another resident's room and had an incontinence accident.
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During the meeting the facility shared information with the family that will be included in the revised service plan.
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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.
SUPERVISORS NAME: Stephenie Doub
LICENSING EVALUATOR NAME: Albert Johnson
LICENSING EVALUATOR SIGNATURE:

DATE: 08/31/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/31/2021
LIC9099 (FAS) - (06/04)
Page: 3 of 3