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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 392701014
Report Date: 09/11/2023
Date Signed: 09/11/2023 03:35:25 PM


Document Has Been Signed on 09/11/2023 03:35 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
SACRAMENTO AC/SC, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833



FACILITY NAME:OAKMONT OF LODIFACILITY NUMBER:
392701014
ADMINISTRATOR:EUGENIA SMITHFACILITY TYPE:
740
ADDRESS:2905 REYNOLDS RANCH PARKWAYTELEPHONE:
(949) 744-5200
CITY:LODISTATE: CAZIP CODE:
95240
CAPACITY:136CENSUS: 85DATE:
09/11/2023
TYPE OF VISIT:Case Management - Health ChecksUNANNOUNCEDTIME BEGAN:
09:15 AM
MET WITH:Andrea Armstrong, Executive Director TIME COMPLETED:
03:30 PM
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On 09/11/2023 at approximately 9:00 am, Licensing Program Analyst (LPA) Renee Campbell arrived to conduct an unannounced Legal/Non-Compliance visit at facility. LPA met with Andrea Armstrong, Executive Director and explained the purpose of the visit. Administrator Certificate for Andrea Armstrong expires on 12/2023. LPAs observed and reviewed the facility and documents below. LPA observed three residents sitting in common areas conversing. No odors were noted and no deficiencies observed:
In-Service Training
  • Medication Error – 6/15/23 Sign in sheet
  • Infection Control 08/14/23 Sign in sheet and Regulation Print Out
  • Missing Resident Drill/Medication Order Receipt Log – 08/03/23 Sign in sheet, Missing Resident Action Plan
  • Elopement Drill – 09/06/23 Sign in Sheet, Missing Resident Action Plan, Elopement Policy
  • Fall Management 06/20/23, Sign in Sheet, Protocol
  • Medication Order/Receipt Log Audit – 08/09/23; Facility Policy
  • CPR Class 08/29/23

Department of Social Services Requested Documentation:
  • Family Meeting Sign in sheet for 07/20/23
  • Incontinence Program – Protocol, Supply/Price List, Assessment
  • Family Support Group – 08/24/23 and 07/20/23; Flyers for July, August and September
  • Town Hall Meetings
  • Weekly Compliance Meeting reviewing client status – 09/06/23, 08/16/23, 08/09/23
  • Facility Maintenance Check Log for last 3 months.
  • NOC shift supervision visit 06/11/23, 06/25/23, 08/11/23, 08/04/23
  • Regional Sign in log book
809-C
SUPERVISOR'S NAME: Emerita CurielTELEPHONE: (916) 263-4707
LICENSING EVALUATOR NAME: Renee CampbellTELEPHONE: 916-206-6380
LICENSING EVALUATOR SIGNATURE:
DATE: 09/11/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/11/2023
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


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO AC/SC, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
FACILITY NAME: OAKMONT OF LODI
FACILITY NUMBER: 392701014
VISIT DATE: 09/11/2023
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Per the California Code of Regulations, Title 22, Division 6, Chapter 8, no violations were observed during this visit. Exit interview held, copy of report given.
SUPERVISOR'S NAME: Emerita CurielTELEPHONE: (916) 263-4707
LICENSING EVALUATOR NAME: Renee CampbellTELEPHONE: 916-206-6380
LICENSING EVALUATOR SIGNATURE:

DATE: 09/11/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/11/2023
LIC809 (FAS) - (06/04)
Page: 2 of 2