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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 392701014
Report Date: 11/16/2022
Date Signed: 11/16/2022 01:48:22 PM

Unsubstantiated


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
09/23/2022 and conducted by Evaluator Maja Jensen
COMPLAINT CONTROL NUMBER: 27-AS-20220923095918
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
UNANNOUNCEDTIME BEGAN:
10:20 AM
MET WITH:Sara MackedsyTIME COMPLETED:
11:45 AM
ALLEGATION(S):
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9
Resident sustained multiple falls resulting in injuries.
INVESTIGATION FINDINGS:
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On 11/16/22 Licensing Program Analyst (LPA) Maja Jensen arrived at the facility unannounced to continue a complaint investigation in to the above listed allegation. LPA Jensen met with Executive Director Sara Mackedsy and explained the purpose of today's visit.

LPA Jensen reviewed records for Resident 1 (R1) including incident reports and the resident file and resident medical records. LPA Jensen also conducted interviews with 4 staff members. 1 staff member advised that R1 had fallen on 9/29/22. There was no incident report made to licensing for this date. There was however an incident report made for a fall on 9/20/22.

On 10/27/22 Executive Director stated via email that the facility has had challenges meeting reporting requirements but the facility has implemented new processes to ensure reports are made timely.

Continued on LIC 9099C...
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: 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.
LIC9099 (FAS) - (06/04)
Page: 1 of 2
Control Number 27-AS-20220923095918
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: 11/16/2022
NARRATIVE
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Continued from LIC 9099C...

Based on the interviews conducted, the records reviewed and the admission by the Executive Director that the facility has not reported all required incidents, LPA Jensen is unable to confirm the validity of this allegation. The allegation has been determined to be UNSUBSTANTIATED. Although the allegation may have happened, the preponderance of evidence does not prove it.

An exit interview was conducted and a copy of this report, appeal rights and 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
LIC9099 (FAS) - (06/04)
Page: 2 of 2