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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 392701014
Report Date: 11/30/2021
Date Signed: 11/30/2021 03:11:07 PM



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
10/27/2021 and conducted by Evaluator Treana White
PUBLIC
COMPLAINT CONTROL NUMBER: 27-AS-20211027115933
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: 65DATE:
11/30/2021
UNANNOUNCEDTIME BEGAN:
10:10 AM
MET WITH:Jessica Pryor, Executive DirectorTIME COMPLETED:
12:20 PM
ALLEGATION(S):
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Resident has access to hazards.
Staff did not keep residents' information confidential.
INVESTIGATION FINDINGS:
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On 11/30/2021, Licensing Program Analyst (LPA) T. White conducted an unannounced complaint investigation regarding the above allegations. LPA White discussed the purpose of the visit and the elements of the allegations with Executive Director, Jessica Pryor.

During the course of investigation, LPA toured the Memory Care Unit apartments and bathrooms. LPA interviewed 4 staff members and 6 residents. LPA collected the following documents: 6 residents' Physician Reports and 5 staff members contact Information.

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: 11/30/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/30/2021
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 2
Control Number 27-AS-20211027115933
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: 11/30/2021
NARRATIVE
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On 11/23/2021, LPA attempted to interview 6 residents. Based on documentation and observation, LPA was unable to interview 6 of 6 residents based on dementia diagnosis. LPA interviewed 4 staff members, 4 of 4 staff stated residents does not have access to hazards.

On 11/23/2021, LPA toured the Memory Care Unit apartments and bathrooms. LPA observed no hazards during tour. S2 stated the facility conducts sweeps throughout the memory care unit. LPA was unable to prove or disprove if resident has access to hazards.

Based on complaint, staff did not keep resident’s information confidential. LPA spoke with complainant regarding residents’ confidential information. Complainant stated she did not want to provide any information. 4 of 4 staff members stated confidential information is not given out to the public. Staff #1 (S1) stated HIPPA training is provided once a week. LPA is unable to prove or disprove if staff did not keep resident’s information confidential.

Based on information obtained, LPA determined these allegations to be UNSUBSTANTIATED- means that although the allegations may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. There are no citations being issued today.

Exit interview conducted with Executive Director and 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: 11/30/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/30/2021
LIC9099 (FAS) - (06/04)
Page: 2 of 2