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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 392701014
Report Date: 12/27/2022
Date Signed: 12/27/2022 12:33:46 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
10/06/2022 and conducted by Evaluator Maja Jensen
COMPLAINT CONTROL NUMBER: 27-AS-20221006102255
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: 94DATE:
12/27/2022
UNANNOUNCEDTIME BEGAN:
11:31 AM
MET WITH:Hugo LemusTIME COMPLETED:
12:45 PM
ALLEGATION(S):
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Facility did not notify resident's family of change in resident's condition.
INVESTIGATION FINDINGS:
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On 12/27/22 at approximately 11:30am Licensing Program Analyst (LPA) Maja Jensen arrived at facility unannounced to complete a complaint investigation in to the above listed allegation. LPA Jensen met with Regional Health Services Specialist Hugo Lemus and explained the purpose of today's visit.

During the course of the investigation LPA Jensen interviewed a former staff member, a current staff member, multiple resident's responsible parties and reviewed records that include resident file, charting notes, change in condition reports, and medical records for resident 1 (R1).

The responsible parties interviewed all stated that there have been occassions where an incident has occurred or an illness has occurred that was not reported to them. Satff interviewed also confirmed that the facility has not reported all changes in condition to the resident's family members.

Continued on LIC 9099C....

Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Liza KingTELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Maja JensenTELEPHONE: 916-639-5584
LICENSING EVALUATOR SIGNATURE:

DATE: 12/27/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/27/2022
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 3
Control Number 27-AS-20221006102255
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: 12/27/2022
NARRATIVE
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Continued from LIC 9099....
LPA Jensen reviewed documents which show that on 6/18/22 the facility learned that a resident had contracted communicable disease. On 6/21/22, the facility documented that the R1's responsible party was contacted for a request to bring in a PRN and at that time there was no indication that R1 had contracted this communicable disease. On 6/23/22 the resident was hospitalized and the responsible party learned from hospital staff that R1 had contracted a communicable disease.

The records reviewed also showed that R1 had a change in health condition on 2/8/22, 2/18/22 and 7/6/22. There was no record identified showing the resident's responsible party was notified of these changes in condition.

As a result of the interviews conducted and the records reviewed the allegation of Facility did not notify resident's family of change in resident's condition is SUBSTANTIATED. A finding of substantiated means that the preponderance of evidence standard has been met.

Deficiencies are being cited from the California Code of Regulations (CCR) Title 22, Division 6.

An exit interview was conducted and a copy of this report and appeal rights were given.
SUPERVISOR'S NAME: Liza KingTELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Maja JensenTELEPHONE: 916-639-5584
LICENSING EVALUATOR SIGNATURE:

DATE: 12/27/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/27/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 27-AS-20221006102255
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: 12/27/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
01/03/2023
Section Cited
CCR
87466
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87466 Observation of the Resident
The licensee shall ensure that residents are regularly observed for changes in physical, mental, emotional and social functioning and that appropriate assistance is provided when such observation reveals unmet needs. When changes such as unusual weight gains or losses or deterioration of mental ability or a physical health condition are observed, the licensee shall ensure that such changes are documented and brought to the attention of the resident's physician and the resident's responsible person, if any. This requirement was not met as evidenced by:
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Licensee will submit a plan to conduct a training for reporting a change in condition to responsible parties by Plan of Correction due date. The plan will be emailed to maja.jensen@dss.ca.gov
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Based on LPA's interviews with responsible parties and a review of R1's resident file, medical records and charting notes, the facility failed to notify R1's responsible party that R1 had contracted a communicable disease and failed to disclose the fact that the resident was suffering from a communicable disease when the responsible was contacted for the purposes of bringing in PRN medication. This poses a potential 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: 12/27/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/27/2022
LIC9099 (FAS) - (06/04)
Page: 3 of 3