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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 392701014
Report Date: 06/16/2022
Date Signed: 06/20/2022 04:55:23 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
04/12/2022 and conducted by Evaluator Maja Jensen
COMPLAINT CONTROL NUMBER: 27-AS-20220412155054
FACILITY NAME:OAKMONT OF LODIFACILITY NUMBER:
392701014
ADMINISTRATOR:PRYOR, JESSICAFACILITY TYPE:
740
ADDRESS:2905 REYNOLDS RANCH PARKWAYTELEPHONE:
(949) 744-5200
CITY:LODISTATE: CAZIP CODE:
95240
CAPACITY:136CENSUS: DATE:
06/16/2022
UNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Jessica ProrTIME COMPLETED:
06:00 PM
ALLEGATION(S):
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Facility is short staffed.
Unqualified staff providing medication.
Residents not being provided medications in a timely manner.
Residents left in soiled diapers for extended amount of time.
INVESTIGATION FINDINGS:
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Licensing Program Analysts (LPAs) Maja Jensen and Treana White arrived at facility on 6/16/22 unannounced to continue the complaint investigation into the above listed allegations.

LPAs Jensen and White have completed site visits on three separate occasions to investigate the complaint allegations during which time they toured the facility including but not limited to the main reception area, the grounds, the medication room, the kitchen, the dining hall, the common social areas, resident rooms and the memory care units. LPAs also engaged with several residents during the course of these visits.

LPAs Jensen interviewed 2 residents, 5 staff members, 2 family members of residents. LPA Jensen also reviewed records that included but is not limited to training records for staff and med techs, and staffing agency expenditures.

Continued on 9099C....
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Liza KingTELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Maja JensenTELEPHONE: 916-639-5584
LICENSING EVALUATOR SIGNATURE:

DATE: 06/20/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/20/2022
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 7
Control Number 27-AS-20220412155054
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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LPA Jensen also reviewed the resident file for R1 which included physician orders, physician chart notes, faxes, medication clarification forms, pharmacy orders and shift reports.

The facility is short staffed
Based on interviews with 2 residents, 2 family members of residents and 5 staff members and a records review the preponderance of evidence standard has been met therefore this allegation is SUBSTANTIATED.

Unqualified staff providing medication.
Based on interviews with 2 staff members and a records review the preponderance of evidence standard has been met therefore this allegation is SUBSTANTIATED.

Residents not being provided medications in a timely manner.
Based on interviews with 4 staff members and a records review the preponderance of evidence standard has been met therefore this allegation is SUBSTANTIATED.

Residents left in soiled diapers for extended amount of time.
Based on interviews with two resident, 2 family members of residents and 2 staff members the preponderance of evidence standard has been met therefore this allegation is SUBSTANTIATED.

LPA Jensen was unable to complete report due to time constraints and returned 6/20/22 to deliver complaint investigation findings. An exit interview was conducted with Executive Director. A copy of this report and Appeal Rights given to Jessica Pryor.
SUPERVISOR'S NAME: Liza KingTELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Maja JensenTELEPHONE: 916-639-5584
LICENSING EVALUATOR SIGNATURE:

DATE: 06/20/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/20/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 7
Control Number 27-AS-20220412155054
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 B
06/30/2022
Section Cited
CCR
87411(a)
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Personnel Requirements - General

Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs.

This requirement was not met as evidenced by:
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The Licensee agrees to submit monthly reports for 3 months beginning 7/1/22 detailing progress on recruiting and hiring of new staff as well a report on number of staff that are no longer employed with the memory care unit, or have taken leave. The Licensee also agrees to submit in the report every incident of a call out or no show for a shift by agency or by staff. The Licensee can add any relevant information to this report as is deemed useful or necessary. The report shall be emailed to maja.jensen@dss.ca.gov.
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Based on interviews with staff, the memory care director, the executive director, care staff, med techs, and family members of residents there is a consensus that the facility was short staffed for periods of time. This poses a potential health and safety risk to residents and care.
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Type B
06/28/2022
Section Cited
CCR
87625(b)(2)
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Managed Incontinence

(b) In addition to Section 87611, General Requirements for Allowable Health Conditions, the licensee shall be responsible for the following:

(1) Ensuring that residents who can benefit from scheduled toileting are assisted or reminded to go to the bathroom at regular intervals rather than being diapered.

(2) Ensuring that incontinent residents are checked during those periods of time when they are known to be incontinent, including during the night.

(3) Ensuring that incontinent residents are kept clean and dry and that the facility remains free of odors from incontinence.

(4) Ensuring that bowel and/or bladder programs are designed by an appropriately skilled professional with training and experience in care of elderly persons with bowel and/or bladder dysfunction and development of retraining programs for restoration of normal patterns of continence.

(5) Ensuring that the appropriately skilled professional developing the bowel and/or bladder program provide training to facility staff responsible for implementation of the program.

(6) Ensuring that re-assessment of the resident's condition and the evaluation of the effectiveness of the bowel and/or bladder program be performed by an appropriately skilled professional.

(7) Ensuring that the condition of the skin exposed to urine and stool is evaluated regularly to ensure that skin breakdown is not occurring.

(8) Privacy shall be afforded when care is provided.

(9) Ensuring that fluids are not withheld to control incontinence.

(10) Ensuring that an incontinent resident is not catheterized to control incontinence for the convenience of the licensee.

This requirement was not as evidenced by:
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Licensee agrees to request a corporate regional specialist to come and develop a plan on how to remain in compliance with regulations. Confirmation of the regional specialist’s deployment will be emailed to Community Care Licensing (CCL) at maja.jensen@dss.ca.gov by 6/28/22. The plan developed by the regional specialist to remain in compliance will be emailed to CCL by 7/28/22.
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Based on interviews with staff, residents and family members of residents in care, residents are waiting excessive amounts of time for incontinence care in the evenings which is resulting in skin rashes and other health conditions.
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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: Liza KingTELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Maja JensenTELEPHONE: 916-639-5584
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: 06/20/2022
LIC9099 (FAS) - (06/04)
Page: 3 of 7
Control Number 27-AS-20220412155054
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
07/28/2022
Section Cited
HSC
1569.69(a)(1)
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Employees assisting residents with self-administration of medication; training requirements

(a) Each residential care facility for the elderly licensed under this chapter shall ensure that each employee of the facility who assists residents with the self-administration of medications meets the following training requirements:
(1) In facilities licensed to provide care for 16 or more persons, the employee shall complete 16 hours of initial training. This training shall consist of eight hours of hands-on shadowing training, which shall be completed prior to assisting with the self-administration of medications, and eight hours of other training or instruction, as described in subdivision (f), which shall be completed within the first two weeks of employment.
This requirement was not met as evidenced by:





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The Licensee has conducted a job fair on 6/14/22 and hired 9 new employees. Licensee agrees to notify CCLD by email to maja.jensen@dss.ca.gov how many of the 9 staff members resulted in new permanent employees. Licensee agrees to continue recruiting through job fairs and any other means necessary and will submit training verification records indicating compliance with the regulation for all memory care unit med tech staff by 7/28/22.
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Based on interviews with two staff members, staff was asked to conduct medication administration activities that they were not qualified or trained to do. This poses a 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: Liza KingTELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Maja JensenTELEPHONE: 916-639-5584
LICENSING EVALUATOR SIGNATURE:

DATE: 06/20/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/20/2022
LIC9099 (FAS) - (06/04)
Page: 4 of 7
Control Number 27-AS-20220412155054
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 B
07/28/2022
Section Cited
CCR
87465(a)(4)
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7
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:
....
(4) The licensee shall assist residents with self-administered medications as needed.
This requirement was not met as evidenced by:
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The Licensee agrees to have the newly hired wellness nurse submit a medication administration improvement plan to CCLD by email by 6/28/22.
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Based on interviews with residents and staff instances occured when medication administration was delayed.
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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: Liza KingTELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Maja JensenTELEPHONE: 916-639-5584
LICENSING EVALUATOR SIGNATURE:

DATE: 06/20/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/20/2022
LIC9099 (FAS) - (06/04)
Page: 5 of 7
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
04/12/2022 and conducted by Evaluator Maja Jensen
COMPLAINT CONTROL NUMBER: 27-AS-20220412155054

FACILITY NAME:OAKMONT OF LODIFACILITY NUMBER:
392701014
ADMINISTRATOR:PRYOR, JESSICAFACILITY TYPE:
740
ADDRESS:2905 REYNOLDS RANCH PARKWAYTELEPHONE:
(949) 744-5200
CITY:LODISTATE: CAZIP CODE:
95240
CAPACITY:136CENSUS: DATE:
06/16/2022
UNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:TIME COMPLETED:
06:00 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Staff hit resident.
Staff not providing adequate services to residents in care.
INVESTIGATION FINDINGS:
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2
3
4
5
6
7
8
9
10
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13
Licensing Program Analysts (LPAs) Maja Jensen and Treana White arrived at facility unannounced to continue the complaint investigation into the above listed allegations.

LPAs Jensen and White have completed site visits on three seperate occassions to investigate the complaint allegations during which time they toured the facility including but not limited to the main reception area, the grounds, the medication room, the kitchen, the dining hall, the common social areas, resident rooms and the memory care units. LPAs also engaged with several residents during the course of these visits.

LPAs Jensen interviewed 2 residents, 5 staff members, 2 family members of residents. LPA Jensen also reviewed records that included but is not limited to training records for staff and med techs, and staffing agency expenditures.

Continued on 9099C....
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Liza KingTELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Maja JensenTELEPHONE: 916-639-5584
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: 6 of 7
Control Number 27-AS-20220412155054
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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Staff not providing adequate services to residents in care.
Based on interviews with staff members and LPA Jensen's observation and interactions with residents the preponderance of evidence standard has not been met, therefore the above allegations are determined to be UNSUBSTANTIATED.

Staff hit resident.
Based on interviews with staff members and LPA Jensen's observation and interactions with the resident in question the preponderance of evidence standard has not been met, therefore the above allegations are determined to be UNSUBSTANTIATED.

An exit interview was conducted with Executive Director Jessica Pryor and copy of this report was given.
SUPERVISOR'S NAME: Liza KingTELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Maja JensenTELEPHONE: 916-639-5584
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)
Page: 7 of 7