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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 392700475
Report Date: 08/08/2024
Date Signed: 08/08/2024 10:02:10 AM


Document Has Been Signed on 08/08/2024 10:02 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827



FACILITY NAME:OAKS AT INGLEWOOD ASSISTED LIVING, THEFACILITY NUMBER:
392700475
ADMINISTRATOR:BRITTANY ANDREWSFACILITY TYPE:
740
ADDRESS:6725 INGLEWOOD AVETELEPHONE:
(209) 957-6257
CITY:STOCKTONSTATE: CAZIP CODE:
95207
CAPACITY:86CENSUS: 98DATE:
08/08/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Tha ChayTIME COMPLETED:
10:15 AM
NARRATIVE
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Licensing Program Analyst (LPA) Maja Jensen arrived on 8/8/24 for an unannounced case management to follow up on an incident report made by the facility. LPA Jensen met with Tha Chay and explained the purpose of today’s visit. Per facility’s Unusual Incident/Injury Report, on 04/20/2020, at approximately 7:30 am, facility staff answered Resident 1’s (R1’s) call. R1 reported she fell and hit her head. 911 was called.

The Department conducted an investigation which consisted of a review of medical records and facility records. Records indicate that R1 was admitted to the facility on March 6, 2020. Between the dates of 3/11/2020 and 4/16/2020, facility notes document that R1 complained of pain 6 times on 5 different dates and facility did not seek medical attention for any of these 6 incidents. On 4/20/24 R1 was sent to the hospital due to a fall during which she hit her head, she was admitted to the hospital and diagnosed with severe sepsis, acute kidney injury, metabolic acidosis, hyponatremia and candidiasis. On 04/22/2020 R1 was pronounced dead at the hospital. The death certificate listed multi organ failure, septic shock, septicemia with Escherichia coli, complicated urinary tract infection due to infected urinary cyst as immediate causes of death with congestive heart failure and atrial fibrillation as other significant conditions contributing to death but not resulting in the underlying cause of death.

Based on the review of the medical records, and other miscellaneous documents the investigation shows that despite R1’s repeated complaints of pain, the facility did not contact R1’s physician or seek medical treatment which lead to death from septic shock, septicemia with Escherichia coli, and an infected urinary cyst.

The following deficiencies were observed (see LIC 809D) and cited from the California Code of Regulations, Title 22, and California Health and Safety Code. This incident is currently under review and a future civil penalty may apply based on 1569.49(f) H&S. Failure to correct the deficiencies may also result in civil penalties.

Exit interview conducted and appeal rights provided.

SUPERVISOR'S NAME: Lisa RiosTELEPHONE: (916) 969-9685
LICENSING EVALUATOR NAME: Maja JensenTELEPHONE: (916) 639-5584
LICENSING EVALUATOR SIGNATURE:
DATE: 08/08/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/08/2024
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 08/08/2024 10:02 AM - 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
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827


FACILITY NAME: OAKS AT INGLEWOOD ASSISTED LIVING, THE
FACILITY NUMBER: 392700475

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/08/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
08/09/2024
Section Cited
CCR
87465(a)(1)

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Incidental Medical and Dental Care
The licensee shall arrange, or assist in arranging, for medical and dental care appropriate to the conditions and needs of residents. This requirement was not as evidenced by:
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The Administrator agrees to send an attestation declaring they have read, understood and will comply with CCR 87465 by 8/9/24.
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Based on review of facility records, R1 complained of pain on 6 separate occasions with no attempt by facility staff to obtain medical care appropriate to R1’s condition. This poses an immediate risk to the health, safety and personal rights of 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: Lisa RiosTELEPHONE: (916) 969-9685
LICENSING EVALUATOR NAME: Maja JensenTELEPHONE: (916) 639-5584
LICENSING EVALUATOR SIGNATURE:
DATE: 08/08/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/08/2024
LIC809 (FAS) - (06/04)
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