392701014-5-18-2023-27-AS-KHOS-CSXLDU-20230619084031

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 392701014
Report Date: 05/18/2023
Date Signed: 05/18/2023 03:32:58 PM

Substantiated

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
11/01/2022 and conducted by Evaluator Michael Bilger

COMPLAINT CONTROL NUMBER: 27-AS-20221101105452

FACILITY NAME:	OAKMONT OF LODI		FACILITY NUMBER:	392701014
ADMINISTRATOR:	SARA MACKEDSY		FACILITY TYPE:	740
ADDRESS:	2905 REYNOLDS RANCH PARKWAY		TELEPHONE:	(949) 744-5200
CITY:	LODI	STATE: CA	ZIP CODE:	95240
CAPACITY:	136	CENSUS: 83	DATE:	05/18/2023
		UNANNOUNCED	TIME BEGAN:	02:30 PM
MET WITH:	Sara Mackedsy		TIME COMPLETED:	03:00 PM

ALLEGATION(S):

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Questionable Death

INVESTIGATION FINDINGS:

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On 5-18-23 at 2:30pm, Licensing Program Analyst (LPA) Michael Bilger arrived unannounced to deliver investigative findings for the complaint allegation noted above. LPA met with Executive Director Sara Mackedsy and explained the purpose of the visit. During this investigation, the department conducted interviews with Staff1 (S1), S2, S3, and S4. The department also conducted interviews with resident2 (R2), R3, and R4. Additional interviews were conducted with witnesses as part of this investigation. The department reviewed facility file documentation and medical information including incident reports, resident care notes, physician fax reports, physician’s report (LIC 602 form), individualized program plan (IPP), death certificate, hospital medical records, and home health records pertaining to resident1 (R1)
Based on interviews and record reviews conducted, it was determined that 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. Per these reports, R1 sustained 12 falls in four months. R1’s last fall on 9-28-22 resulted in R1 being sent out to the local hospital due to an unwitnessed fall with bruising on R1’s head. {Cont. on 9099C}

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Liza King	TELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Michael Bilger	TELEPHONE: 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.

LIC9099 (FAS) - (06/04)

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Control Number 27-AS-20221101105452

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: 05/18/2023

NARRATIVE

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Based on medical record review it was determined that “Given the history, physical exam, and review of laboratory and imaging studies the patient is determined to be unsafe for discharge and requires higher level of care.” Additional interviews and record reviews determined that facility did not update R1’s care plan or implement any sort of fall mitigation plan during the above 4 months period to aid in the prevention of R1 from sustaining falls. Interviews conducted further revealed that the increased level of supervision for R1 was limited to placing R1 in the common areas so staff could monitor R1. It was determined that based on the number of falls sustained by R1, this intervention was not a sufficient plan to mitigate falls.
After R1 returned to the facility from the hospital stay as a result of the fall occurring on 9-28-22, R1 was placed on hospice care. Hospice care began on 9-29-22. On 10-5-22, R1 passed away. A review of death certificate revealed the immediate cause of death was cerebral atherosclerosis with no other significant conditions contributing to death.

Based on interviews and record reviews conducted by the Department for this investigation, it is determined that R1 sustained multiple falls in a short period time without facility implementing appropriate and effective intervention resulting in injury and eventual death of R1. As a result, this allegation is SUBSTANTIATED. The following deficiencies were observed (see LIC 9099-D) and cited from the California Code of Regulations, Health and Safety Codes. Failure to correct the deficiency may result in additional civil penalties. At the time of the complaint visit, the issuance of a Civil Penalty was still being determined and the licensee was informed that a civil penalty might be assessed based on Health and Safety Code § 1569.49(e) . 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 King	TELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Michael Bilger	TELEPHONE: 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

LIC9099 (FAS) - (06/04)

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Control Number 27-AS-20221101105452

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: 05/18/2023

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Deficiency Dismissed Type A 05/19/2023 Section Cited HSC 1569.312(a)	1 2 3 4 5 6 7	Basic Service Requirements. Every facility required to be licensed under this chapter shall provide at least the following basic services: (a) Care and supervision as defined in Section 1569.2. This requirement was not met as evidenced by:	1 2 3 4 5 6 7	Licensee will implement a fall mitigation plan which shall include but not be limited to: Procedures for identifying fall risk residents and various interventions to accommodate residents. Completed plan to be submitted to LPA by POC due date.
	8 9 10 11 12 13 14	Based on record reviews and interviews, R1 sustained multiple falls over a period of four months without Licensee ensuring appropriate intervention to aid in R1’s care and supervision resulting in injury and eventual death. This posed an immediate risk to residents health, safety, and resident rights.	8 9 10 11 12 13 14	Licensee will conduct staff training on fall prevention. Training date to be submitted to LPA by POC due date. Training to be completed and proof of completed training to be submitted to LPA no later than 2 weeks from the date of citation issuance.
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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 King	TELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Michael Bilger	TELEPHONE: 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

LIC9099 (FAS) - (06/04)

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