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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 392701014
Report Date: 06/20/2022
Date Signed: 07/18/2022 01:06:28 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
04/18/2022 and conducted by Evaluator Maja Jensen
COMPLAINT CONTROL NUMBER: 27-AS-20220418105958
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: 88DATE:
06/20/2022
UNANNOUNCEDTIME BEGAN:
10:41 AM
MET WITH:Jessica PryorTIME COMPLETED:
04:45 PM
ALLEGATION(S):
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9
Facility did not ensure that resident's medication is available to resident
INVESTIGATION FINDINGS:
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3
4
5
6
7
8
9
10
11
12
13
On 6/20/22 Licensing Program Analyst (LPA) Maja Jensen arrived at facility to continue the complaint investigation in to the above listed allegation. LPA Jensen met with Executive Director Jessica Pryor and explained the purpose of today's visit.

LPA Jensen conducted interviews with 4 staff members. In addition, LPA Jensen reviewed Special Incident Reports, Medication Administration Records, Medication Clarification Reports, Change of Condition Reporting Forms, physician fax reports, RX receipts and RX order forms.

Based on interviews and record reviews the preponderance of evidence standard has been met therefore the allegation "facility did not ensure that resident's medication is available to resident" is SUBSTANTIATED.

Deficiencies were cited on the corresponding LIC 9099D. An exit interview was conducted and a copy of this report along with appeal rights was given to the Executive Director Jessica Pryor.
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 3
Control Number 27-AS-20220418105958
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: 06/20/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
06/20/2022
Section Cited
HSC
1569.2(c)
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(c) "Care and supervision" means the facility assumes responsibility for, or provides or promises to provide in the future, ongoing assistance with activities of daily living without which the resident’s physical health, mental health, safety, or welfare would be endangered. Assistance includes assistance with taking medications, money management, or personal care. This requirement was not met as evidenced by:
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7
Since the occurrence of this incident the facility has hired nurses, contracted with Agencies for nurses, hired a wellness nurse to monitor the medication room, enlisted the support of corporate regional technical assistance experts and is conducting medication room audits and conducted additional training therefore no further plan of correction is required at this time. The Licensee agrees to report any and all medication errors or missed doses to Community Care Licensing within the required regulatory time frame.
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Based on interviews and record reviews, resident 1 (R1) ran out of prescription medication. This poses an immediate threat to teh safety and well being of residents in care.
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14
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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: 2 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
04/18/2022 and conducted by Evaluator Maja Jensen
COMPLAINT CONTROL NUMBER: 27-AS-20220418105958

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: 88DATE:
06/20/2022
UNANNOUNCEDTIME BEGAN:
10:41 AM
MET WITH:Jessica PryorTIME COMPLETED:
04:45 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Staff did not seek medical care for resident
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
On 6/20/22 Licensing Program Analyst (LPA) Maja Jensen arrived at facility to continue the complaint investigation in to the above listed allegation. LPA Jensen met with Executive Director Jessica Pryor and explained the purpose of today's visit.

LPA Jensen conducted interviews with 4 staff members. In addition, LPA Jensen reviewed Special Incident Reports, Medication Administration Records, Medication Clarification Reports, Change of Condition Reporting Forms, physician fax reports, RX receipts and RX order forms.

Based on interviews and record reviews the preponderance of evidence standard has not been met therefore the allegation "Staff did not seek mdical care for resident" is UNSUBSTANTIATED.

An exit interview was conducted and a copy of this report along with appeal rights was given to the Executive Director Jessica Pryor.
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: 06/20/2022
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: 3 of 3