392701014-11-3-2022-27-AS-LKIG-CN2PRB-20230113103220

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 392701014
Report Date: 11/03/2022
Date Signed: 11/03/2022 02:03:14 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 LODI		FACILITY NUMBER:	392701014
ADMINISTRATOR:	SARA MACKEDSY		FACILITY TYPE:	740
ADDRESS:	2905 REYNOLDS RANCH PARKWAY		TELEPHONE:	(949) 744-5200
CITY:	LODI	STATE: CA	ZIP CODE:	95240
CAPACITY:	136	CENSUS:	DATE:	11/03/2022
		UNANNOUNCED	TIME BEGAN:	06:40 AM
MET WITH:	Sara Mackedsy		TIME COMPLETED:	09:30 AM

ALLEGATION(S):

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Residents are left in soiled diapers overnight
Facility staff did not adequately provide residents adequate care and supervision

INVESTIGATION FINDINGS:

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On 11/3/22 Licensing Program Analyst (LPA) Maja Jensen arrived unannounced at facility at 6:40am to continue a complaint investigation in to teh above allegations. Licensing Program Analyst met with Staff 1 (S1) and Staff 2 (S2), explained the purpose of the visit and toured the Memory Care unit of the facility. Later in the morning at approximately 8:30am met with Memory Care Director Ann Franco and Executive Director Sara Mackedsy and explained the purpose of today's visit.

LPA Jensen was informed by S1 and S2 that the staff who worked overnight had left the facility when they arrived. Memory Care Director Ann Franco advised LPA Jensen that facility procedure is for the night shift to do walk through of residents room and provide an update as part of the shift change. S1 advised LPA that no walk through had occured.

Continued on LIC 9099C...

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Liza King	TELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Maja Jensen	TELEPHONE: 916-639-5584
LICENSING EVALUATOR SIGNATURE:	DATE: 11/03/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/03/2022

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 4

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: 11/03/2022

NARRATIVE

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LPA Jensen toured resident rooms for resident 1 (R1), Resident 2 (R2) Resident 3 (R3) and Resident 4 (R4). LPA Jensen observed R1's brief to be fully saturated. LPA Jensen observed R3's brief to also be fully saturated and R3's bed was observed to be saturated with a saturation ring of approximately 2 feet. Photos were taken in R1's room at 6:58am and Photos were taken in R3's room at 7:05am. R1's room is a double occupancy room with R1 residing in the portion of the room furthest from the door. The portion of R1's room occupied by another resident was observed to contain 3 wheel chairs, a walker and hoses and clothing on the floor which poses a tripping hazard for R1. R3's room was observed to have clothing that needed to be laundered overflowing from the hamper and clothes on the bathroom floor. At 7:41am LPA Jensen went to the room for resident 12 (R12) and observed torn paper on the floor in the main living area and bathroom. LPA Jensen also observed R12 to be sleeping with no clothing, and no sheets on the bed. LPA Jensen also observed a soiled discarded brief on the mattress and urine stains on the mattress. LPA Jensen activated the alert button in the rooms for R7, R11 and R12 and there was no response.

LPA Jensen interviewed Hospice worker 1 (H1) who has 3 clients in the memory care unit. H1 provides services for R5 and R6. H1 stated she is at the facility 5 days a week. H1 stated on 10/31/22 at approximately 11am she observed R6 to be double briefed. H1 stated that her supervisor H2 also witnessed R6 to be double briefed. H1 stated that on 11/1/22 she observed R5 was observed to have no sheets, no brief and a urine soaked blanket.

LPA Jensen went in to the 3 resident rooms, R7, R11 and R12, and activated the call alert. There was no response in 3 of 3 resident rooms.

LPA Jensen interviewed 4 staff members during the course of the visit. LPA Jensen interviewed 1 Hospice worker. LPA Jensen interviewed 3 residents from the assisted living unit. 3 of 3 residents interviewed from assisted living stated they felt that the facility was insufficiently staffed. LPA Jensen interviewed 3 responsible parties for residents 3 of 3 responsible parties. 1 of 4 staff members, 3 of 3 residents and 3 of 3 responsible parties felt that there were occasions that residents did not receive the care and supervision they needed.

Continued on LIC 9099C...

SUPERVISOR'S NAME: Liza King	TELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Maja Jensen	TELEPHONE: 916-639-5584
LICENSING EVALUATOR SIGNATURE:	DATE: 11/03/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/03/2022

LIC9099 (FAS) - (06/04)

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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: 11/03/2022

NARRATIVE

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Based on LPA's observation of 2 of 4 residents in fully saturated briefs and photos taken in addition too interviews with responsible parties, staff and hospice worker, residents are not receiving timely incontinence care. The allegation has been determined to be SUBSTANTIATED. A finding of substantiated means that the preponderance of evidence standard has been met

Based on LPA's observation of resident rooms, interviews with responsible parties, residents and a hospice worker and a lack of response by staff to 3 of 3 resident rooms where the call alert was activated, residents are not receiving the care and supervision they require. The allegation has been determined to be SUBSTANTIATED. A finding of substantiated means that the preponderance of evidence standard has been met.

Deficiencies are being cited on this day. Failure to correct deficiencies may result in the issuance of civil penalties.

An exit interview was conducted and a copy of this report and appeal rights was provided to Executive Director Sara Mackedsy.

SUPERVISOR'S NAME: Liza King	TELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Maja Jensen	TELEPHONE: 916-639-5584
LICENSING EVALUATOR SIGNATURE:	DATE: 11/03/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/03/2022

LIC9099 (FAS) - (06/04)

Page: 3 of 4

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: 11/03/2022

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 11/04/2022 Section Cited CCR 87464(f)(1)	1 2 3 4 5 6 7	(f) Basic services shall at a minimum include: (1) Care and supervision as defined in Section 87101(c)(3) and Health and Safety Code section 1569.2(c). This requirement was not met as evidenced by:	1 2 3 4 5 6 7	Licensee agrees to move the call alert system equipment to the medication room and have the medication technician responsible for calls. Licensee will email an attestation and a sign in and sign out form to LPA Jensen at maja.jensen@dss.ca.gov by POC due date.
	8 9 10 11 12 13 14	Based on LPA's observation of a lack of response in 3 of 3 resident rooms to the call alert system and LPA Jensen's observation of resident rooms and interviews with the hospice worker, residents and responsible parties, residents are not receiving the care and supervision they require. This poses an immediate health, safety and personal rights risk to residents in care.	8 9 10 11 12 13 14
Type B 11/10/2022 Section Cited CCR 87625(b)(3)	1 2 3 4 5 6 7	(b) ...the licensee shall be responsible for the following:... (3) Ensuring that incontinent residents are kept clean and dry and that the facility remains free of odors from incontinence. This requirement was not met as evidenced by:	1 2 3 4 5 6 7	Licensee agrees to have medication technician verify that complete rounds have been done to ensure incontinence care has been provided. Licensee will email verification of training related to the new responsibilitie to LPA by 11/10/22
	8 9 10 11 12 13 14	Based on LPA's observation of 2 of 4 residents in fully saturated briefs, interviews with responsible parties, interviews with hospice worker and LPA Jensen's observation of odor in 1 of 4 resident rooms, residents are not being kept clean and dry. This poses a potential health, safety and personal rights risk to residents in care.	8 9 10 11 12 13 14

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 King	TELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Maja Jensen	TELEPHONE: 916-639-5584
LICENSING EVALUATOR SIGNATURE:	DATE: 11/03/2022

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/03/2022

LIC9099 (FAS) - (06/04)

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