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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 392701014
Report Date: 01/26/2023
Date Signed: 01/26/2023 05:15:14 PM


Document Has Been Signed on 01/26/2023 05:15 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: 88DATE:
01/26/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
03:15 PM
MET WITH:Sara MackedsyTIME COMPLETED:
03:45 PM
NARRATIVE
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On 1-26-23 at 3:15, Licensing Program Analyst (LPA) Michael Bilger arrived unannounced to conduct a case management visit regarding medication management. LPA met with Administrator Sara Mackedsy and explained the purpose of the visit. LPA interviewed Administrator and Staff 3 (S3). LPA also reviewed physician’s orders for resident1 (R1). Additionally, LPA reviewed facility’s medication training material. Based on interviews and record reviewed, it was determined that R1 had an order written on 7-21-22 by a Physician to give a Zoloft medication “twice a day for 30 days.” Additionally, the order contained a refill option for up to 5 refills. Medication was stopped on the 30th day. Interviews conducted revealed that the physician’s order as written should have been questioned and clarified with Physician to determine if R1 required the continued use of this medication. A review of facility’s medication training material revealed training component which states: “Communication with physician including instructions to follow up with physician over any concerns, including additional follow ups after 24 hours if no response is received.” Based on interviews and record reviews, it was determined facility did not conduct a necessary follow up in regard to a medication order discrepancy.

As a result of this case management visit, citation is issued under Title 22, Division 6 and noted on LIC 9099D. A civil penalty in the amount $250 is issued in addition to the citation due to a repeat violation within a 12-month period. An exit interview was conducted with Sara Mackedsy and a copy of this report was left with Sara. Appeal rights provided.

SUPERVISOR'S NAME: Liza KingTELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Michael BilgerTELEPHONE: 916-862-4722
LICENSING EVALUATOR SIGNATURE:
DATE: 01/26/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/26/2023
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


Document Has Been Signed on 01/26/2023 05:15 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: 01/26/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Request Denied
Type B
02/24/2023
Section Cited
CCR
87465(a)(4)

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87465(a)(4). Incidental Medical and Dental Care. (a) A plan for incidental medical and dental care shall be developed by each facility...(4)The licensee shall assist residents with self administered medications as needed. This requirement was not met as evidenced by:
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Licensee will ensure completed staff training on medication orders and communication with physician as appropriate. Proof of completed training to be submitted to LPA by POC due date.
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 Based on interview and record review, licensee did not ensure a necessary follow up for a medication order discrepancy as noted in facility medication training material.. This posed a potential health and safety risk to resident 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: Michael BilgerTELEPHONE: 916-862-4722
LICENSING EVALUATOR SIGNATURE:
DATE: 01/26/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/26/2023
LIC809 (FAS) - (06/04)
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