<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 392701014
Report Date: 07/21/2022
Date Signed: 07/21/2022 03:47:13 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
05/10/2022 and conducted by Evaluator Treana White
PUBLIC
COMPLAINT CONTROL NUMBER: 27-AS-20220510142331
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: 96DATE:
07/21/2022
UNANNOUNCEDTIME BEGAN:
09:05 AM
MET WITH:Patrick Olvera,Regional Memory Care SpecialistTIME COMPLETED:
02:00 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Facility did not ensure resident's room was cleaned.
Staff not ensuring resident's are taking medications.
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
On 07/21/2022 at 9:05 AM Licensing Program Analyst (LPA) T. White arrived at facility unannounced to codunct complaint investigation related to the above allegations. LPA met with Virginia Alvarez, Health Service Director and Patrick Olvera, Regional Memory Care Specialist. LPA explained the purpose of today's visit. During course of investigation, LPA conducted a tour, interviewed 4 staff members and collected documentation.

Facility did not ensure residents rooms was cleaned
On 07/21/2022, LPA interviewed 4 staff members. Based on interviews, 2 of 4 staff stated facility did not ensure residents rooms were cleaned. LPA toured the memory care side including but not limited to bedrooms, bathrooms, kitchen area, and common area. During tour, LPA observed what appeared to be smeared feces on Resident #1 (R1) chaise. LPA observed Resident #2 (R2) and Resident #3 (R3) had a malodorous smell. Based on interviews, 2 of 4 staff and 1 witness stated residents would have a bowel movement and it would take an extended amount of time to clean up.
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: 07/21/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/21/2022
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 6
Control Number 27-AS-20220510142331
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: 07/21/2022
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
Staff not ensuring resident’s medications

On 07/21/2022, LPA interviewed 4 staff members. Based on interviews, 2 of 4 staff stated staff are not ensuring resident’s medications. Based on LPA Jensen complaint on 06/20/2022 LPA 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 "Staff not ensuring resident’s medications” is SUBSTANTIATED.

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-20220418105958.

Exit interview conducted with Health Service Director and Regional Memory Care Specialist. 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: 07/21/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/21/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 6
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
05/10/2022 and conducted by Evaluator Treana White
PUBLIC
COMPLAINT CONTROL NUMBER: 27-AS-20220510142331

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: 96DATE:
07/21/2022
UNANNOUNCEDTIME BEGAN:
09:05 AM
MET WITH:Patrick Olvera, Regional Memory Care SpecialisTIME COMPLETED:
02:00 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Facility is not providing activities for resident's.
Facility not meeting resident's needs.
Facility not providing records to resident's responsible party.
Resident is isolated.
Facility did not follow hospice medical directives
Staff chemically restrained resident.
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
On 07/21/2022 at 9:05 AM Licensing Program Analyst (LPA) T. White arrived at facility unannounced to codunct complaint investigation related to the above allegations. LPA met with Virginia Alvarez, Health Service Director and Patrick Olvera, Regional Memory Care Specialist. LPA explained the purpose of today's visit. During course of investigation, LPA conducted a tour, interviewed 4 staff members and collected documentation.

Facility is not providing activities for residents.
During course of investigation, LPA interviewed 4 staff members. Based on interviews, 2 of 4 staff members stated there was a period of time there were no activities. However, LPA collected activities calendar from April 2022 through July 2022. Based on documentation and observation, the facility is currently following activities calendar. Based LPA tour, LPA observed residents participating in sing along, Zumba, and "Happy Hour". LPA is unable to prove or disprove if allegation did or did not occur.

Report continues on 9099C...
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: 07/21/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/21/2022
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 6
Control Number 27-AS-20220510142331
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: 07/21/2022
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
Facility is not meeting resident’s needs.

On 07/21/2022, LPA interviewed 4 staff members. Based on interviews, 2 of 4 staff stated facility is meeting residents needs. However, 1 of 4 staff stated residents needs were not being met when there was staffing problems. Staff stated residents’ needs are currently being met. LPA is unable to prove or disprove if allegation did or did not occur.

Facility not providing records to resident’s responsible party

On 07/21/2022, LPA interviewed 4 staff members. Based on interviews, 2 of 4 staff stated facility is providing records to resident’s responsible party. Based on interview with Staff #2 (S2), the facility notifies residents responsible parties if there has been an incident or change of condition immediately. Based on June 2022 incident reports, responsible party's were provided resident information. LPA is unable to prove or disprove if allegation did or did not occur.

Resident is isolated.

On 07/21/2022, LPA interviewed 4 staff members. Based on interviews, 3 of 4 staff stated residents are not isolated in their rooms. 3 of 4 staff stated the only occurrence of isolation was due to COVID or medical, such as bed bugs, scabies, ect. Based on tour, LPA did not observe any residents isolated in their rooms. LPA is unable to prove or disprove if allegation did or did not occur.

Facility did not follow hospice medicals directives

On 07/21/2022, LPA interviewed 4 staff members. Based on interviews, 3 of 4 staff stated facility follows hospice medial directives for residents. Based on observation, facility currently has 1 hospice resident. Based on documentation, the facility is following hospice medical directives. LPA is unable to prove or disprove if allegation did or did not occur.

Report continues on 9099C.

SUPERVISOR'S NAME: Liza KingTELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Treana WhiteTELEPHONE: (510) 566-9342
LICENSING EVALUATOR SIGNATURE:

DATE: 07/21/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/21/2022
LIC9099 (FAS) - (06/04)
Page: 4 of 6
Control Number 27-AS-20220510142331
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: 07/21/2022
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
Staff chemically restrained residents

On 07/21/2022, LPA interviewed 4 staff members. Based on interviews, 3 of 4 staff stated staff do not chemically restrain residents. 1 of 4 staff does not provide care or administer medications to residents. LPA interviewed 1 witness, based on interview, witness stated staff does not restrain residents chemically. Based on Medication Administration Records (MARs) review, LPA did not observe an over dose in medication. Based on observation, residents were participating in activities and alert. 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 Health Service Director and Regional Memory Care Specialist. A copy of report given.

SUPERVISOR'S NAME: Liza KingTELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Treana WhiteTELEPHONE: (510) 566-9342
LICENSING EVALUATOR SIGNATURE:

DATE: 07/21/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/21/2022
LIC9099 (FAS) - (06/04)
Page: 5 of 6
Control Number 27-AS-20220510142331
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: 07/21/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
07/25/2022
Section Cited
CCR
87303(a)
1
2
3
4
5
6
7
87303(a): Maintenance and Operation:
(a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors.
This requirement was not met as evidence by:
1
2
3
4
5
6
7
Facility agreed to clean Residents apartment and chaise and submit proof to CCLD by POC date.
8
9
10
11
12
13
14
Based on interviews and observation, the facility did not comply with section cited above in 87303(a).LPA observed what appeared to be feces smeared on residents chaise which poses an immediate health and safety risk 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 KingTELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Treana WhiteTELEPHONE: (510) 566-9342
LICENSING EVALUATOR SIGNATURE:

DATE: 07/21/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/21/2022
LIC9099 (FAS) - (06/04)
Page: 6 of 6