392701014-11-22-2023-27-AS-LRIS-CYHPNL-20231214102808

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 392701014
Report Date: 11/22/2023
Date Signed: 11/22/2023 03:57:20 PM

Substantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

This is an official report of an unannounced visit/investigation of a complaint received in our office on
06/23/2023 and conducted by Evaluator Renee Campbell

PUBLIC

COMPLAINT CONTROL NUMBER: 27-AS-20230623092425

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:	0	CENSUS: 86	DATE:	11/22/2023
		UNANNOUNCED	TIME BEGAN:	02:00 PM
MET WITH:	Andrea Armstrong, Administrator		TIME COMPLETED:	04:00 PM

ALLEGATION(S):

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Staff did not follow resident's care plan

INVESTIGATION FINDINGS:

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On 11/22/2023, Licensing Program Analyst (LPA) Renee Campbell arrived unannounced to the facility to complete an investigation and present the findings. LPA Campbell met with Administrator Andrea Armstrong and stated the purpose of the visit.
Regarding the allegation that staff did not follow residents care plan, LPA Campbell observed R1's assessment and fall care plan written by the facility. Of the four current staff members interviewed about R1's care plan, none of the staff reported observing the interventions found on R1's care plan. R1's power of attorney also reported that no lowered bed or elevated toilet seat was observed as required in R1's care plan.

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Lisa Rios	TELEPHONE: (916) 969-9685
LICENSING EVALUATOR NAME: Renee Campbell	TELEPHONE: (916) 206-6380
LICENSING EVALUATOR SIGNATURE:	DATE: 11/22/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/22/2023

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-20230623092425

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 11/22/2023

NARRATIVE

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Based on interviews the preponderance of evidence standard has been met, therefore the above allegation(s) are found to be SUBSTANTIATED.

Per California Code of Regulations (CCRs) - Title 22, Div.6, Ch. 8, deficiencies are being cited on the attached 9099D during this visit. If any deficiencies are not corrected by the noted due dates; civil penalties may be assessed. The Administrator was provided a copy of their rights (LIC9058) and their signature on this form acknowledges receipt of these rights.
An exit interview was conducted, and a copy of this report was provided.

SUPERVISOR'S NAME: Lisa Rios	TELEPHONE: (916) 969-9685
LICENSING EVALUATOR NAME: Renee Campbell	TELEPHONE: (916) 206-6380
LICENSING EVALUATOR SIGNATURE:	DATE: 11/22/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/22/2023

LIC9099 (FAS) - (06/04)

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Control Number 27-AS-20230623092425

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 11/22/2023

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 11/30/2023 Section Cited CCR 87633(a)(4)	1 2 3 4 5 6 7	87633(a)(4) The licensee shall be permitted to ...retain residents .. when ...following conditions are met: A written hospice care plan which specifies ... necessary medical intervention … to supplement the care ... provided by the facility. This requirement is not met as evidenced by	1 2 3 4 5 6 7	Licensee shall provide a statement of correction and acknowledgement stating that they have read the regulation above and provide the new accountability procedure for resident interventions by POC date.
	8 9 10 11 12 13 14	Based on observation and interviews, the licensee failed to implement the care, services and necessary medical interventions related to the terminal illness. This poses a potential health, safety and personal rights risk to residents in care.	8 9 10 11 12 13 14
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	1 2 3 4 5 6 7		1 2 3 4 5 6 7

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: Lisa Rios	TELEPHONE: (916) 969-9685
LICENSING EVALUATOR NAME: Renee Campbell	TELEPHONE: (916) 206-6380
LICENSING EVALUATOR SIGNATURE:	DATE: 11/22/2023

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/22/2023

LIC9099 (FAS) - (06/04)

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