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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 392701014
Report Date: 05/18/2023
Date Signed: 05/18/2023 03:35:40 PM


Document Has Been Signed on 05/18/2023 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
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: 83DATE:
05/18/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
03:00 PM
MET WITH:Sara MackedsyTIME COMPLETED:
03:45 PM
NARRATIVE
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On 5-18-23 and 3:00pm, Licensing Program Analyst (LPA) Michael Bilger arrived unannounced to conduct a case management visit regarding incident reporting requirements and provision of safety requirements.. LPA met with Executive Director Sara Mackedsy and explained the purpose of the visit. LPA reviewed an investigation conducted by the department regarding complaint #27-AS-20221101105452. Based on record reviews and interviews conducted, it was determined that resident1 (R1) sustained multiple falls on 6-10-22, 7-6-22, 7-7-22, 7-14-22, 7-18-22, 7-19-22, 7-21-22, 7-31-22, 9-8-22, 9-13-22, 9-17-22, and 9-28-22. From these falls incidents and record review, it was revealed that only 2 of the 12 incidents were reported by facility to licensing department per regulatory requirements. Additionally, it was further revealed that facility did not initiate a fall mitigation plan for R1 in relation to the falls. .

As a result of today’s case management, citations are issued under Title 22, Division 6, Chapter 8. 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: 05/18/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/18/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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Document Has Been Signed on 05/18/2023 03:35 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: 05/18/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Request Denied
Type A
05/19/2023
Section Cited
CCR
87211(a)(1)(D)

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Reporting Requirements. (a) Each licensee shall furnish to the licensing agency such reports as the Department may require, including, but not limited to, the following: (1) A written report shall be submitted to the licensing agency…within seven days of the occurrence of...(D) Any incident which threatens the welfare, safety or health of any resident..This requirement was not met as evidenced by:
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Licensee will read regulation 87211 and submit a signed declaration of understanding to LPA by POC due date.
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Based on record review and interview, licensee did not ensure the reporting of multiple falls of R1 during a four month period. This posed an immediate health and safety risk to resident in care.
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Request Denied
Type A
05/19/2023
Section Cited
CCR87405(h)(5)

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Administrator-Qualifications and Duties. (h) The administrator shall have the responsibility to: (5) Provide or ensure the provision of services to the residents with appropriate regard for the residents' physical and mental well-being and needs…This requirement was not met as evidenced by:
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Licensee will read regulation 87405(h)(5) and submit a signed declaration of understanding to LPA by POC due date.
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 Based on interviews and record reviews, Administrator did not ensure a sufficient provision to aid in fall prevention of R1 after R1 sustained multiple falls over a four-month period which led to injury and eventual death of R1. This posed an immediate health and safety 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: Michael BilgerTELEPHONE: 916-862-4722
LICENSING EVALUATOR SIGNATURE:
DATE: 05/18/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/18/2023
LIC809 (FAS) - (06/04)
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