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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 392701014
Report Date: 11/16/2022
Date Signed: 11/16/2022 02:08:02 PM


Document Has Been Signed on 11/16/2022 02:08 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:SARA MACKEDSYFACILITY TYPE:
740
ADDRESS:2905 REYNOLDS RANCH PARKWAYTELEPHONE:
(949) 744-5200
CITY:LODISTATE: CAZIP CODE:
95240
CAPACITY:136CENSUS: 92DATE:
11/16/2022
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
12:30 PM
MET WITH:Sara MackedsyTIME COMPLETED:
01:20 PM
NARRATIVE
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On 11/16/22 Licensing Program Analyst (LPA) Maja Jensen arrived at the facility unannounced to conduct a case management for deficiencies observed during the course of an investigation in to complaint # 27-AS-20220923095918 and 27-AS-20221006102255. LPA Jensen met with Executive Director Sara Mackedsy and explained the purpose of today's visit.

On 8/15/22 LPA Jensen reviewed a physician's order placing resident 1 (R1) on a soft mechanical diet. During the course of an interview with Executive Director Sara Mackedsy, the Executive Director confirmed that the order was not followed until a second order for a special diet was received on 9/23/22.

On 10/27/22 LPA Jensen received an email from Executive Director Sara Mackedsy indicating that the facility has had challenges meeting reporting requirements. LPA Jensen also received an incident report for resident 2 (R2) on 11/1/22 for an event that occurred on 10/12/22. LPA Jensen also reviewed records for resident 3 (R3) and determined at least 4 incidents occurred in 2022 that were not reported.

Deficiencies are being cited from the California Code of Regulations, Title 22. Failure to correct the deficiency may result in the assessment of civil penalties.

An exit interview was conducted and a copy of this report and appeal rights, along with a confidential names list was provided to the Executive Director.
SUPERVISOR'S NAME: Liza KingTELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Maja JensenTELEPHONE: 916-639-5584
LICENSING EVALUATOR SIGNATURE:
DATE: 11/16/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/16/2022
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 11/16/2022 02:08 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: 11/16/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
11/17/2022
Section Cited

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87555 General Food Service Requirements
...
(7) Modified diets prescribed by a resident's physician as a medical necessity shall be provided.This requirement was not met as evidenced by:
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Based on LPA Jensen's review of a physician order dated 8/15/22 and the Executive's Director's confirmation that it was not followed until 9/23/22 when the order was sent again creating a choking risk for the resident. This poses an immediate threat to the health, safety and personal rights of residents in care.
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Type B
11/17/2022
Section Cited

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87211 Reporting Requirements
(1) A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence ...
This requirement was not met as evidenced by...
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Based on resident records reviewed, the incident report reviewed and the email received from the Executive Director, the facility has not reported incidents timely. This poses a potential threat to the health, safety and personal rights risk to residents in care.
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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: 11/16/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/16/2022
LIC809 (FAS) - (06/04)
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