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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 392701014
Report Date: 10/17/2023
Date Signed: 10/17/2023 03:00:53 PM


Document Has Been Signed on 10/17/2023 03:00 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 SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827



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: 88DATE:
10/17/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Andrea ArmstrongTIME COMPLETED:
03:15 PM
NARRATIVE
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Licensing Program Analyst (LPA) Avelina Martinez arrived at facility unannounced to conduct a case management visit on October 17, 2023 at 10:00 AM. LPA met with Andrea Armstrong and explained the purpose of the visit.

The purpose of the visit today, is in response to follow up on an AWOL that occurred on October 06, 2023. It was learned resident 1 (R1) successfully left the facility unattended at 9:14 PM, and a samaritan from the local Lodi community returned R1 to Oakmont of Lodi facility at 9:30 PM. An immediate $500.00 civil penalty shall be assessed on October 17, 2023 due to lack of care and supervision and an immediate health and safety risk to R1. Moreover, R1's LIC 602 Health Certification Form indicates, they are able to leave the facility unattended. However, the LIC 602 Health Certification Form indicates R1 has Dementia. In addition, staff 1 (S1) reported if R1 left the facility unattended they would not have the capacity to return to the facility on their own. It was also learned R1 was provided a wander guard band after the October 06, 2023 elopement. Furthermore, R1 is in the process of transitioning into the memory care unit. LPA Martinez requested that R1's LIC 602 Health Certification form be updated, and that a reassessment be conducted. The requested documents should be emailed to LPA Martinez by October 23, 2023. Additionally, the current LIC 602 Health Certification form is signed by a nurse practitioner, and the updated LIC 602 should be signed by Physician (Medical Doctor).

Continued...

SUPERVISOR'S NAME: Liza KingTELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Avelina MartinezTELEPHONE: (916) 431-8935
LICENSING EVALUATOR SIGNATURE:
DATE: 10/17/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/17/2023
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 3


Document Has Been Signed on 10/17/2023 03:32 PM - It Cannot Be Edited

Document is an Amendment of Original Document on 10/17/2023 03:14 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827


FACILITY NAME: OAKMONT OF LODI
FACILITY NUMBER: 392701014

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/17/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
10/18/2023
Section Cited
CCR
87307(e)

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87307 (e) Personal Accommodations and Services: Facilities providing services to residents who have physical or mental disabilities shall assure the inaccessibility of...swimming pools, or similar bodies of water... This requirement was not met as evidence by:
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Facility Administrator agrees to contact all outside vendors and informed them they cannot leave swimming pool door open by POC date 10/8/2023. Facility Administrator will email formal letter confirming POC has been completed by POC date 10/18/2023 5 PM.
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Based on observation and inspection of swimming pool gate, LPA observed the pool gate to be opened and left unattended. This posed an immediate health and safety risk to residents in care.
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Type A
10/18/2023
Section Cited
HSC1569.312(d)

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1569.312(d)Basic services requirements: Being aware of the resident's general whereabouts, although the resident may travel independently in the community. This requirement was not met as evidence by: Based on file reviews and interviews,
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Facility Administrator agrees to conduct elopement drill and training for all staff by POC date 10/18/2023. Facility Administrator will email LPA training logs by POC date 10/18/2023 by 5 PM.
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 the Licensee did not ensure staff were aware of R1 general whereabouts as R1 was found by a local Lodi samaritan, and the Samaritan returned R1 to the facility at 9:30 PM. This posed an immediate health and safety risk to R1.
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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: Avelina MartinezTELEPHONE: (916) 431-8935
LICENSING EVALUATOR SIGNATURE:
DATE: 10/17/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/17/2023
LIC809 (FAS) - (06/04)
Page: 2 of 3


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME: OAKMONT OF LODI
FACILITY NUMBER: 392701014
VISIT DATE: 10/17/2023
NARRATIVE
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On today's visit at 10:13 AM, LPA Martinez observed the facility pool gate to be open, and the pool was left unattended. LPA Martinez closed the gate. At this time, management staff were attending a meeting and LPA Martinez was waiting to speak to the Executive Director. LPA Martinez observed the pool gate to be open and the pool to be left unattended for the second time at 10:20 AM. LPA Martinez informed front receptionist to close the gate. At this time, Management staff were attending a meeting. As a result, of the pool being made accessible to residents in care, an immediate civil penalty shall be assessed on October 17, 2023 in the amount of $500.00.

The following deficiencies were observed and cited from the California Code of Regulations, Title 22, and California Health and Safety Code. The deficiencies can be found on the 809-D page.

An exit interview was conducted, and a copy of the 809 report, 809-D page, and appeals rights were provided to the facility.

SUPERVISOR'S NAME: Liza KingTELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Avelina MartinezTELEPHONE: (916) 431-8935
LICENSING EVALUATOR SIGNATURE:

DATE: 10/17/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/17/2023
LIC809 (FAS) - (06/04)
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