392701014-6-16-2022-27-AS-KHOS-CFUHFU-20220629061006

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 392701014
Report Date: 06/16/2022
Date Signed: 06/16/2022 04:14:24 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, 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
06/14/2022 and conducted by Evaluator Treana White

PUBLIC

COMPLAINT CONTROL NUMBER: 27-AS-20220614153408

FACILITY NAME:	OAKMONT OF LODI		FACILITY NUMBER:	392701014
ADMINISTRATOR:	PRYOR, JESSICA		FACILITY TYPE:	740
ADDRESS:	2905 REYNOLDS RANCH PARKWAY		TELEPHONE:	(949) 744-5200
CITY:	LODI	STATE: CA	ZIP CODE:	95240
CAPACITY:	136	CENSUS: 88	DATE:	06/16/2022
		UNANNOUNCED	TIME BEGAN:	09:35 AM
MET WITH:	Jessica Pryor, Executive Director		TIME COMPLETED:	03:45 PM

ALLEGATION(S):

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Facility is not following Covid-19 Infection Safety Protocols.
Facility is not following Covid-19 Testing Protocols.
Medications are not being administered to residents according to physicians instructions.

INVESTIGATION FINDINGS:

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On 06/16/2022 at 9:35 AM Licensing Program Analysts (LPAs) T. White and M. Jensen arrived at facility unannounced to open a complaint investigation related to the above allegations. LPAs met with Execuitve Director, Jessica Pryor and explained the purpose of today's visit. During course of investigation, LPA conducted interviews with 3 staff member and collected documentation.

Facility is not following Covid-19 Infection Safety Protocols.
On 06/16/2022, LPA conducted a tour with Staff #4 (S4) regarding PPE supplies. LPA observed sufficient PPE supplies present at the facility. Based on tour with S4, each COVID positive resident is placed on quarantine and has a PPE station present in front of each COVID positive resident apartment. However, during tour via Facetime, LPA observed there are 7 COVID positive residents quarantined at the facility. LPA toured 7 residents apartments and observed 2 of 7 residents have a trash can located in their apartment. Based on observation, 5 of 7 residents did not have a trash can located in their apartments for staff to throw away potentially contaminated PPE.
Report continues on 9099C.

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Liza King	TELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Treana White	TELEPHONE: (510) 566-9342
LICENSING EVALUATOR SIGNATURE:	DATE: 06/16/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/16/2022

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 4

Control Number 27-AS-20220614153408

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 LODI	FACILITY NUMBER: 392701014
	VISIT DATE: 06/16/2022

NARRATIVE

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Facility is not following Covid-19 Testing Protocols.
During course of investigation, LPA interviewed 3 staff members. Based on 3 of 3 staff, the facility is not conducting response testing unless residents shows signs and symptoms. Based on Staff #5 (S5) interview, the facility conducted response testing with all residents, but the residents with signs and symptoms test were only sent to the lab for results. S5 stated staff are not testing unless staff shows signs and symptoms or an in-home test shows positive.

Medications are not being administered to residents according to physicians instructions.
Based on incident report submitted to CCLD on 06/14/2022 regarding medication error. On 06/08/2022 at 9:00pm, Resident #1 (R1) was given medication at the wrong time. Based on interview with Staff #1 (S1), R1 prescribed medication (Lasix) ischeduled to be administered at 8:00am. However, Staff #3 (S3) administered medication to R1 at 8:00pm.

Based on LPA observations and interviews which were conducted and record reviews, the preponderance of evidence standard has been met, therefore the above allegations are found to be SUBSTANTIATED. California Code of Regulations (Title 22, Division 6, Chapter 8), are being cited on the attached LIC 9099D.

Exit interview conducted with Executive Director. A copy of report and appeal rights given.

SUPERVISOR'S NAME: Liza King	TELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Treana White	TELEPHONE: (510) 566-9342
LICENSING EVALUATOR SIGNATURE:	DATE: 06/16/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/16/2022

LIC9099 (FAS) - (06/04)

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Control Number 27-AS-20220614153408

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 LODI	FACILITY NUMBER: 392701014
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 06/16/2022

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 06/17/2022 Section Cited CCR 87307(d)(3)(B)	1 2 3 4 5 6 7	87307(d)(3)(B): Personal Accommodations and Services (d)The following space and safety provisions shall apply to all facilities:(3) All persons shall be protected against hazards...B) Information and instruction regarding life protection and other appropriate subjects. This requirement was not met as evidence by:	1 2 3 4 5 6 7	ED agreed to provide trash cans for each resident and submit proof to CCLD by POC. Executive Director agreed to conduct an in-service training with staff regarding COVID Infection Safety by 06/21/2022.
	8 9 10 11 12 13 14	Based on observation and interview, licensee is not complying with the section cited above in 87307(d)(3)(B). Based on observation, the facility is not following COVID Infection Safety Protocols which poses an immediate health and safety risks to residents in care.	8 9 10 11 12 13 14
Type A 06/17/2022 Section Cited HSC 1569.58	1 2 3 4 5 6 7	HSC 1569.58(a)(2)Employee Actions: Engaged in conduct that is inimical to the health, morals, welfare, or safety of either an individual in or receiving services from the facility, or the people of the State of California. This requirement is not met as evidence by:	1 2 3 4 5 6 7	Executive Director agreed to conduct an in-service training with staff regarding COVID Testing by 06/21/2022.
	8 9 10 11 12 13 14	Based on observation and interview licensee did not comply with the section cited in 1569.58. LPA observed facility is not following COVID testing protocols which poses an immediate 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: Liza King	TELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Treana White	TELEPHONE: (510) 566-9342
LICENSING EVALUATOR SIGNATURE:	DATE: 06/16/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/16/2022

LIC9099 (FAS) - (06/04)

Page: 3 of 4

Control Number 27-AS-20220614153408

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 LODI	FACILITY NUMBER: 392701014
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 06/16/2022

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 06/17/2022 Section Cited CCR 87465(c)(2)	1 2 3 4 5 6 7	87465(c)(2): Incidental Medical and Dental Care: (c) If the resident's physician has stated in writing that the resident is unable to... (2) Once ordered by the physician the medication is given according to the physician's directions. This requirement was not met as evidence by:	1 2 3 4 5 6 7	Executive Director agreed to create a written plan regarding medications and submit proof to CCLD by 06/21/2022.
	8 9 10 11 12 13 14	Based on documentation, licensee did not comply with the section cited above in 87465(c)(2). LPA observed Medications are not being administered to residents according to physicians instructions which poses an immediate health and safety risks to residents in care.	8 9 10 11 12 13 14
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

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: Liza King	TELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Treana White	TELEPHONE: (510) 566-9342
LICENSING EVALUATOR SIGNATURE:	DATE: 06/16/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/16/2022

LIC9099 (FAS) - (06/04)

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