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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 392701014
Report Date: 02/14/2022
Date Signed: 02/14/2022 02:54:54 PM



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
11/12/2021 and conducted by Evaluator Treana White
PUBLIC
COMPLAINT CONTROL NUMBER: 27-AS-20211112082804
FACILITY NAME:OAKMONT OF LODIFACILITY NUMBER:
392701014
ADMINISTRATOR:PRYOR, JESSICAFACILITY TYPE:
740
ADDRESS:2905 REYNOLDS RANCH PARKWAYTELEPHONE:
(949) 744-5200
CITY:LODISTATE: CAZIP CODE:
95240
CAPACITY:136CENSUS: 87DATE:
02/14/2022
UNANNOUNCEDTIME BEGAN:
09:10 AM
MET WITH:Jessica Pryor, Executive DirectorTIME COMPLETED:
01:00 PM
ALLEGATION(S):
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Staff did not adhere to resident's physician order
Staff did not assist resident with incontinence care
Staff did not seek medical care in a timely manner for resident
INVESTIGATION FINDINGS:
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On 02/14/2022, Licensing Program Analyst (LPA) T. White conducted an unannounced complaint investigation regarding the above allegations. LPA White discussed the purpose of the visit and the elements of the allegations with Executive Director (ED) Jessica Pryor.

During the course of investigation, LPA collected the following documents: Staff/Resident Roster, Actual hours worked, Incontinence care, LIC 602, Needs/Service Care Plan, Narrative charting/ADLs, and Incident Reports. LPA conducted interviews with 4 staff members and 2 residents.

Report continues on 9099C.
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Liza KingTELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Treana WhiteTELEPHONE: (510) 566-9342
LICENSING EVALUATOR SIGNATURE:

DATE: 02/14/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/14/2022
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 6
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
11/12/2021 and conducted by Evaluator Treana White
PUBLIC
COMPLAINT CONTROL NUMBER: 27-AS-20211112082804

FACILITY NAME:OAKMONT OF LODIFACILITY NUMBER:
392701014
ADMINISTRATOR:PRYOR, JESSICAFACILITY TYPE:
740
ADDRESS:2905 REYNOLDS RANCH PARKWAYTELEPHONE:
(949) 744-5200
CITY:LODISTATE: CAZIP CODE:
95240
CAPACITY:136CENSUS: 87DATE:
02/14/2022
UNANNOUNCEDTIME BEGAN:
09:10 AM
MET WITH:Jessica Pryor, Executive DirectorTIME COMPLETED:
01:00 PM
ALLEGATION(S):
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9
Resident sustained a medical condition while in care
Staff did not report change of condition to responsible party
INVESTIGATION FINDINGS:
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On 02/14/2022, Licensing Program Analyst (LPA) T. White conducted an unannounced complaint investigation regarding the above allegation. LPA White discussed the purpose of the visit and the elements of the allegations with Executive Director (ED) Jessica Pryor.

During the course of investigation, LPA collected the following documents: Staff/Resident Roster, Actual hours worked, Incontinence care, LIC 602, Needs/Service Care Plan, Narrative charting/ADLs, and Incident Reports. LPA conducted interviews with 4 staff members and 2 residents.

Report continues on 9099C.
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Liza KingTELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Treana WhiteTELEPHONE: (510) 566-9342
LICENSING EVALUATOR SIGNATURE:

DATE: 02/14/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/14/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 2 of 6
Control Number 27-AS-20211112082804
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: 02/14/2022
NARRATIVE
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The investigation was conducted by Investigation Branch (IB) Investigator Fizza Shahzad as an assignment. IB Shahzad requested medical records for Resident #1 (R1). R1’s medical records were obtained and reviewed. The Department has determined the following as it relates to the above allegation.

Based on complaint, resident sustained a medical condition while in care. R1 was brought to the hospital due to a rash to unchanged brief. Based on R1’s medical records, R1 was not septic and did not have 30 open wounds. R1 was diagnosed with Cellulitis and abcess of buttocks, for which R1 was prescribed clotrimazole/betamethasone and Mupirocoin ointment. On 11/12/2021, it was noted at R1’s follow up that the infection on buttocks is improving as expected. On 11/13/20/2021, a physical exam was conducted, it was noted there were multiple areas of healed infection on left and right buttocks. No abcess was reported. R1 was later discharged.

Based on interviews with 2 of 4 staff members, R1 did not sustain a medical condition while in care. S4 stated, when staff assessed R1 upon arrival, staff observed R1 had a rash. However, 2 of 4 staff members were unaware of the incident. LPA is unable to prove or disprove if incident occurred.

Staff did not report change of condition to responsible party


LPA interviewed 4 staff members. Based on staff interviews, 3 of 4 staff members were unaware of the incident. Based on incident report dated 11/01/2021, R1 developed a rash the week prior and R1's daughter was made aware and transported R1 to Urgent Care to be evaluated.

Based on S4's interview and documentation, R1's daughter and Physician was contacted on 11/01/2021 and 11/03/2021. Based on notes, R1 was sent to the hospital on 11/03/2021 regarding an open sore. LPA is unable to prove or disprove if incident occurred.

Based on interviews, observations and record review, it is determined that facility is currently meeting the regulatory food supply. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED.

An exit interview was conducted with Executive Director and a copy of report given.
SUPERVISOR'S NAME: Liza KingTELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Treana WhiteTELEPHONE: (510) 566-9342
LICENSING EVALUATOR SIGNATURE:

DATE: 02/14/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/14/2022
LIC9099 (FAS) - (06/04)
Page: 3 of 6
Control Number 27-AS-20211112082804
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: 02/14/2022
NARRATIVE
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Staff did not adhere to resident's physician order
LPA interviewed 4 staff members. Based on staff interviews, 3 of 4 staff members were unaware of the incident. Based on documentation, Resident #1 (R1) physician report indicates R1 needed to apply cream to rash on 11/01/2021. Based on interview and documentation, S4 stated R1's Physician was not responding due to change in R1's Physician. Based on documentation, the Physician responded on 11/03/2021. S4 stated R1 did not receive the cream prescribed until 72 hours later. S4 stated staff was unable to adhere to R1's physician order due to no response from R1's previous Physician.

Staff did not assist resident with incontinence care

LPA interviewed 2 residents. Based on resident interviews, 2 of 2 residents stated they do not need assistance with incontinence care. Based on documentation, both residents are diagnosed with dementia. LPA was unable to obtain additional information.

LPA interviewed 4 staff members. Based on staff interviews, 2 of 4 staff members were unaware of the incident. Based on care plan, R1 required reminders to go to the bathrooms. However, Based on R1's Physician Report, R1 is unable to care for own toileting needs. S4 stated R1 arrived to facility around dinner time. S4 stated staff did not assess or change R1 immediately. Staff went based on R1's care plan.

Based on documentation and S4's interview, R1 moved in on 10/25/2021 during the evening and his brief was changed on 10/26/2021 during diner time. Based on S1 and S4, R1 was not changed in a timely manner. S1 stated staff should have immediately changed R1 when he moved in. S1 stated R1's care plan was updated and credited R1's family was credited care.

Staff did not seek medical care in a timely manner for resident
LPA interviewed 4 staff members. Based on staff interviews, 3 of 4 staff were unaware of the incident. Based on S4's interview, staff did not seek medical care in a timely manner for R1. S4 stated R1 moved in on 10/25/2021 and staff observed R1's rash on 10/28/2021, staff did not seek medical care within 24 hours.
S4 stated she contacted the office on 11/01/2021 and faxed questions regarding R1's rash on 11/03/2021.
S4 stated staff requested medical care within 48 to 72 hours.

Based on LPA's observation and interviews which were conducted and record reviews, the preponderance of evidence standard has been met, therefore the above allegations are found to be SUBSTANTIATED. California Code of Regulations (Title 22, Division 6, Chapter 8), are being cited on the attached LIC 9099D.

An exit interview was conducted with Executive Director. A copy of this report and Appeal Rights given.
SUPERVISOR'S NAME: Liza KingTELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Treana WhiteTELEPHONE: (510) 566-9342
LICENSING EVALUATOR SIGNATURE:

DATE: 02/14/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/14/2022
LIC9099 (FAS) - (06/04)
Page: 4 of 6
Control Number 27-AS-20211112082804
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: 02/14/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
02/17/2022
Section Cited
CCR
87465(c)(2)
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87465(c)(2): Incidental Medical and Dental Care:(c) If the resident's physician has stated in writing that the resident is unable to determine his/her own need for nonprescription PRN medication but can communicate his/her symptoms clearly, facility staff designated by the licensee shall be permitted to assist the resident with self-administration, provided all of the following requirements are met:
(1) There is written direction from a physician, on a prescription blank, specifying the name of the resident, the name of the medication, all of the information in Section 87465(e), instructions regarding a time or circumstance (if any) when it should be discontinued, and an indication when the physician should be contacted for a medication re-evaluation.
(2) Once ordered by the physician the medication is given according to the physician's directions. This requirement was not met as evidence by:
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Executive Director agreed to conduct an in-service training to ensure staff is following physician's order and submit proof to CCLD by POC date
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Based on interview, Licensee did not comply with the section cited above in 87465(c)(2). Based on interview, staff did not adhere to R1's physician's order which poses an immediate health and safety risks to residents in care
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Type A
02/17/2022
Section Cited
CCR
87465(j)
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87465(j): Incidental Medical and Dental Care: (j) In all facilities licensed for sixteen (16) persons or more... assuring that each resident receives needed first aid and needed emergency medical services and for assisting residents as needed with self-administration of medications. The names of the staff employees so responsible and the designated procedures shall be documented and made known to all residents and staff. This requirement was not met as evidence by:
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Executive Director agreed to conduct an in-service training to ensure staff is following staff seeking medical care in a timely manner and submit proof to CCLD by POC date.
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Based on LPA interview and documentation, facility did not comply with the section cited 87465(j). Based on interview, staff did not seek medical care in a timely manner, which poses an immediate health and safety risks 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: Treana WhiteTELEPHONE: (510) 566-9342
LICENSING EVALUATOR SIGNATURE:

DATE: 02/14/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/14/2022
LIC9099 (FAS) - (06/04)
Page: 5 of 6
Control Number 27-AS-20211112082804
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: 02/14/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
02/25/2022
Section Cited
CCR
87625(b)(2)
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Managed Incontinence: (b) In addition to Section 87611, General Requirements for Allowable Health Conditions, the licensee shall be responsible for the following:
(2) Ensuring that incontinent residents are checked during those periods of time when they are known to be incontinent, including during the night. This requirement was not met as evidence by:
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Executive Director agreed to conduct an in-service training with staff and submit proof to CCLD by POC date.
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Based on LPA interviews and documentation, Licensee did not comply with the section cited above in 87465(b)(2). Based on interview, staff did not assist with resident with incontinence care, which poses as a potential health and safety risks to residents in care.
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CCR
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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: Treana WhiteTELEPHONE: (510) 566-9342
LICENSING EVALUATOR SIGNATURE:

DATE: 02/14/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/14/2022
LIC9099 (FAS) - (06/04)
Page: 6 of 6