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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 392701014
Report Date: 07/12/2022
Date Signed: 07/12/2022 03:51:39 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
04/25/2022 and conducted by Evaluator Treana White
PUBLIC
COMPLAINT CONTROL NUMBER: 27-AS-20220425121904
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: 92DATE:
07/12/2022
UNANNOUNCEDTIME BEGAN:
09:35 AM
MET WITH:Kelly Goss, Memory Care DirectorTIME COMPLETED:
04:05 PM
ALLEGATION(S):
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9
Staff are not correctly documenting in the MAR
Staff do not give medications to residents correctly
Staff are not properly trained
INVESTIGATION FINDINGS:
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13
On 07/12/2022 at 9:35 AM Licensing Program Analyst (LPA) T. White arrived at facility unannounced to open a complaint investigation related to the above allegations. LPA met with Memory Care Director, Kelly Goss and explained the purpose of today's visit. During course of investigation, LPA conducted interviews with 4 staff members and collected documentation.

Staff are not correctly documenting in the MAR
Based on 4 staff interviews, 3 of 4 staff stated MARs were not correctly documented in the resident records. Based on 04/15/2022 MARs, R2 was unable to take insulin due to incorrect order from hospital. Based on documentation, R2 did not receive insulin. Based on incident reports dated 05/08/2022, 05/09/2022 and 05/15/2022, R2 and R3 missed dosed of medication due to no nurse available to administer medications. On 05/09/2022, R4 missed medications due to no nurse available to administer medications. Based on MARs there is no documentation that R2, R3, and R4 missed insulin.
Report continues on 9099C.
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Liza KingTELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Treana WhiteTELEPHONE: (510) 566-9342
LICENSING EVALUATOR SIGNATURE:

DATE: 07/12/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/12/2022
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 3
Control Number 27-AS-20220425121904
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: 07/12/2022
NARRATIVE
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Continued...

Staff do not give medications to residents correctly
Based on 4 staff interviews, 4 of 4 staff stated medications were not given to residents correctly. 3 of 4 staff stated there are 2 residents who receive insulin from an outside agency. 2 of 4 staff stated if the outside agency does not come to facility to administer insulin, the residents are either sent to the hospital or monitored for any changes in condition. Based on MARs on 05/02/2022, R3 did not receive four medications because it was too late to give. Based on incident reports, R2, R3, and R4 missed insulin medication due to no nurse present at facility. Based on interviews and documentation, staff do not give medications to residents correctly.

Staff are not properly trained
Based on 4 staff interviews, 2 of 4 staff stated staff are not properly trained. LPA reviewed 5 staff training logs. Based on training, LPA observed no completed medication certificate on file for 5 of 5 staff members. On 06/16/2022, LPA 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. Based on information provided, staff are not properly trained.

Based on LPAs 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), the following deficiencies were cited on #27-AS-20220412155054.



Exit interview conducted with Memory Care Director. A copy of report and Appeal Rights given.
SUPERVISOR'S NAME: Liza KingTELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Treana WhiteTELEPHONE: (510) 566-9342
LICENSING EVALUATOR SIGNATURE:

DATE: 07/12/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/12/2022
LIC9099 (FAS) - (06/04)
Page: 3 of 3
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
04/25/2022 and conducted by Evaluator Treana White
COMPLAINT CONTROL NUMBER: 27-AS-20220425121904

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: 92DATE:
07/12/2022
UNANNOUNCEDTIME BEGAN:
09:35 AM
MET WITH:Kelly Goss, Memory Care DirectorTIME COMPLETED:
04:05 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Staff failed to supervise resident resulting in multiple falls and injuries
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
On 07/12/2022 at 9:35 AM Licensing Program Analyst (LPA) T. White arrived at facility unannounced to open a complaint investigation related to the above allegations. LPA met with Memory Care Director, Kelly Goss and explained the purpose of today's visit. During course of investigation, LPA conducted interviews with 4 staff member and collected documentation.

Based on 4 staff interviews, 2 of 4 staff stated Resident #1 (R1) had a history of falls. Based on Staff #2 (S2), the facility attempted to come up with solutions to minimize R1's falls. S2 stated the facility attempted 1 on 1 care supervision, and interventions in the common area with R1. S2 stated fall preventions were in place for R1. However, 2 of 2 staff did not know R1. LPA is unable to prove or disprove if allegation did or did not occur.
Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED.

Exit interview conducted with Memory Care Director and a copy of report given.
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Liza KingTELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Treana WhiteTELEPHONE: (510) 566-9342
LICENSING EVALUATOR SIGNATURE:

DATE: 07/12/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/12/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 2 of 3