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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 392701014
Report Date: 08/24/2022
Date Signed: 08/24/2022 01:26:40 PM


Document Has Been Signed on 08/24/2022 01:26 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		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 LODIFACILITY NUMBER:
392701014
ADMINISTRATOR:PRYOR, JESSICAFACILITY TYPE:
740
ADDRESS:2905 REYNOLDS RANCH PARKWAYTELEPHONE:
(949) 744-5200
CITY:LODISTATE: CAZIP CODE:
95240
CAPACITY:136CENSUS: 95DATE:
08/24/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
11:15 AM
MET WITH:Sara MackedsyTIME COMPLETED:
01:40 PM
NARRATIVE
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On 8/24/22 at approximately 11:15am Licensing Program Analyst (LPA) Maja Jensen arrived at facility unannounced to complete a quarterly site inspection. This visit is a continuation from the visit of 8/18/22. The visit on 8/18/22 was not completed as there was insufficient time to address the deficiencies noted. LPA Jensen met with Executive Director Sara Mackedsy and explained the purpose of today's visit.

During the course of the visit on August 18, 2022, LPA Jensen observed that resident 3 (R3) did not receive prescribed medication on June 17, 18 and August 15.

In addition on August 18, 2022, LPA Jensen pulled the alert cord in resident 1's (R1's) room and there was no response by staff.

Deficiencies are being cited on this day for the observations made on August 18, 2022 as described above.
Further non-compliance will result in civil penalties. An exit interview was conducted and appeal rights were given to Executive Director Sara Mackedsy.
SUPERVISOR'S NAME: Liza KingTELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Maja JensenTELEPHONE: 916-639-5584
LICENSING EVALUATOR SIGNATURE:
DATE: 08/24/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/24/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2


Document Has Been Signed on 08/24/2022 01:26 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 08/24/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/23/2022
Section Cited

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87465 Incidental Medical and Dental Care

The licensee shall provide assistance in meeting necessary medical and dental needs. This requirement was not met as evidenced by:
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Based on interviews and a review of the MAR for R3, R3 did not receive prescribed medication on 6/17/22, 6/18/22 and 8/15/22. Therefore the residents medical needs were not met.
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Type B
08/25/2022
Section Cited

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87464 Basic Services

...(f) Basic services shall at a minimum include:...
(1) Care and supervision...
This requirement was not met as evidenced by:
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Based on LPA's observation and witnessed by R1's responsible party, staff did not respond to an alert signal in R1's room therefore adequate care and supervision was not provided.
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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: 08/24/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/24/2022
LIC809 (FAS) - (06/04)
Page: 2 of 2