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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 392701014
Report Date: 11/21/2023
Date Signed: 11/21/2023 12:07:15 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
10/09/2023 and conducted by Evaluator Avelina Martinez
PUBLIC
COMPLAINT CONTROL NUMBER: 27-AS-20231009115024
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:0CENSUS: 86DATE:
11/21/2023
UNANNOUNCEDTIME BEGAN:
08:30 AM
MET WITH:Andrea ArmstrongTIME COMPLETED:
12:15 PM
ALLEGATION(S):
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Resident is not being given medications as needed
Facility is understaffed
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Avelina Martinez arrived at the facility unannounced on 11/21/2023 at 8:30 AM to deliver complaint findings, LPA met Andrea Armstrong and explained the purpose of the visit.

Throughout the course of the investigation, LPA Martinez conducted interviews, reviewed facility documents, conducted tours of the facility, and shadowed care staff. Based on interviews and file reviews, it was determined the facility did not maintain resident’s 1 (R1) medication list. LPA Martinez requested R1’s medication administration records (MAR). LPA Martinez reviewed the following MAR’s November 2021, December 2021, and October 2023.

It was learned R1 was being administered Amlodipine in November of 2021. On the December 2021 MAR, the resident was not given Amlodipine. The December 2021 MAR states, “physically unable to take” for the following medications: Amlodipine, Daily Vite tablet, Oyster Shell Calcium and Atorvastatin.

Continued...
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Liza KingTELEPHONE: (650) 676-0442
LICENSING EVALUATOR NAME: Avelina MartinezTELEPHONE: (916) 431-8935
LICENSING EVALUATOR SIGNATURE:

DATE: 11/21/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/21/2023
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 5
Control Number 27-AS-20231009115024
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: 11/21/2023
NARRATIVE
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After December 2021, Amlodipine was no longer administered, and the facility had no records of a discontinuance order. LPA Martinez interviewed facility staff, and facility staff did not know the reason why Amlodipine was not being administered. LPA Martinez reviewed R1’ October 2023 MAR. The October 2023 MAR reported R1’s was diagnosed with the following: HTN, Dementia, Hypothyroidism, Dysphagia, Cognitive Communication Deficit.

LPA Martinez also reviewed Lisinopril 10 MG Tablet October 2023 8AM MAR entries. LPA Martinez observed there was no medication administration entry for October 6th 2023. Additionally, the October 2023 MAR did not have notes regarding why Lisinopril was not administered. LPA Martinez conducted interviews with staff regarding change in condition and Hypertension diagnosis. Facility staff were not able to answer if R1’s hypertension diagnosis was changed or if R1’s primary care physician made any changes in regards to medication orders. As a result, the facility did not assist R1 with self administered medications as needed.

In this investigation, it was also learned the facility is understaffed. LPA Martinez reviewed care staff call out logs/work schedule, call button logs, and conducted staff interviews. It was learned call out shifts are left uncovered and resident call button pages are not being responded to in a timely manner due to not enough staff working. LPA Martinez reviewed October 2023 work schedule and counted twenty-three call outs. The October 2023 call button unanswered page announcements ranged from: one to nine times.

Continued...

SUPERVISOR'S NAME: Liza KingTELEPHONE: (650) 676-0442
LICENSING EVALUATOR NAME: Avelina MartinezTELEPHONE: (916) 431-8935
LICENSING EVALUATOR SIGNATURE:

DATE: 11/21/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/21/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 27-AS-20231009115024
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: 11/21/2023
NARRATIVE
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 The longest wait time ranged from: alert never responded to forty-five minutes. Additionally, on October 27, 2023, there were three call outs. The longest wait time was thirty-eight minutes, and the highest unanswered page announcement record was nine times. Furthermore, there were nineteen entries that stated this alert was never responded to on October 27, 2023. During interviews, it was learned from 6:00 AM to 2:30 PM on October 27, 2023, there was one caregiver and one med-tech to cover the Assisted Living unit. Staff reported they did not have time to complete there assigned care staff duties on October 27, 2023.

LPA Martinez also, shadowed care staff on November 13, 2023. It was learned there was a call out by a caregiver during the 6:00 AM to 2:30 PM shift. This shift was not covered until 10:00 AM. As a result, there were two caregivers and one Med-Tech from 6:00 AM to 10:00 AM. From 6:00 AM to 10:00 AM, two care staff had to oversee the 49 residents listed on assisted living unit's assigned care provider sheet. This includes oversight on 4 residents who require two persons assist and 10 residents who require incontinence care. During facility interviews, LPA Martinez was informed residents are left in soiled briefs and not checked on regularly due to not having enough staff. It was determined the facility did not have sufficient staff to meet residents needs.

Moreover, LPA Martinez reviewed the assisted living unit's assigned care provider list on November 13 2023, which listed 49 residents, however, there are 86 residents and 37 residents were unaccounted for. LPA Martinez was informed by care staff that they are responsible for overseeing residents on there assigned care provider list. However, on November 13, 2023, LPA Martinez observed care staff only having time to answer call pages and escort residents who need assistance getting to the dinning room. LPA Martinez determined the facility did not have sufficient care staff working in the assisted living unit on October 13, 2023.

As a result of this investigation, the Department finds these allegations to be Substantiated. A finding that the complaint is substantiated means that the allegations are valid because the preponderance of the evidence standard has been met. Deficiencies cited on the LIC 9099-D, per Title 22 Regulations.


An exit interview was conducted, and a copy of the 9099 report, LIC 9099-D page, and appeal rights were given to the facility.
SUPERVISOR'S NAME: Liza KingTELEPHONE: (650) 676-0442
LICENSING EVALUATOR NAME: Avelina MartinezTELEPHONE: (916) 431-8935
LICENSING EVALUATOR SIGNATURE:

DATE: 11/21/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/21/2023
LIC9099 (FAS) - (06/04)
Page: 3 of 5
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
10/09/2023 and conducted by Evaluator Avelina Martinez
PUBLIC
COMPLAINT CONTROL NUMBER: 27-AS-20231009115024

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:0CENSUS: DATE:
11/21/2023
UNANNOUNCEDTIME BEGAN:
08:30 AM
MET WITH:Andrea Armstrong TIME COMPLETED:
12:15 PM
ALLEGATION(S):
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Facility did not adhere to the Admission Agreement.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Avelina Martinez arrived at the facility unannounced on 11/21/2023 at 8:30 AM to deliver complaint findings, LPA met Andrea Armstrong and explained the purpose of the visit.

Throughout the course of the investigation, LPA Martinez conducted interviews and reviewed facility documents. Based on interviews and file reviews, it was determined the facility's plan of operation states a Licensed Vocational Nurse (LVN) will be in the facility. However, the facility's plan of operation does not state that the LVN will be on facility premises 24/7. The facility's Health Service Director is a LVN, and is present in the facility. Moreover, the facility admission agreement does not state that a LVN will be on the facility's premises 24/7.

Due to the above noted information, 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, and therefore the allegation is unsubstantiated. An exit interview was conducted, and a copy of this report was provided to the facility.
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Liza KingTELEPHONE: (650) 676-0442
LICENSING EVALUATOR NAME: Avelina MartinezTELEPHONE: (916) 431-8935
LICENSING EVALUATOR SIGNATURE:

DATE: 11/21/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/21/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 27-AS-20231009115024
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: 11/21/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Request Denied
Type B
12/05/2023
Section Cited
CCR
87465(a)(4)
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87465(a)(4) Incidental Medical and Dental Care A plan for incidental medical and dental care shall be developed by each facility...the licensee shall assist residents with self-administered medications as needed. This requirement was not met as evidence by
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Facility staff agrees to conduct a reassessment for R1, which includes an audit of R1's medications by POC Date 12/05/2023. Facility staff agrees to email documents to LPA Martinez by POC 12/05/2023 by 5 PM.
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Based on observation and file review, the Licensee did not ensure R1 was being administer their medication listed on their Medication Administration Records This posed a potential health and safety risk to R1.
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Type B
12/05/2023
Section Cited
CCR
87468.2(a)(4)
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87468.2(a)(4) Additional Personal Rights of Residents in Privately Operated Facilities...In addition to the rights listed in Section 87468.1, Personal Rights of Residents in All Facilities...To care, supervision, and services that meet their individual needs and are delivered by staff that are sufficient in
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Facility staff agrees to review staffing schedule to ensure adequate staffing coverage is sufficent. Facility staff agrees to conduct Audit work schedules and task lists. Facility agrees to email staff audit findings to LPA Martinez by 12/05/2023 5 PM.
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numbers...This requirement was not met as evidence by: based on observations, file review, and interviews, the Licensee did not ensure the facility has a sufficient number of staff and that staff are able to meet residents' needs. This posed a potential health and safety to risk to residents.
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Facility recently conducted a job fair, and hired care staff.
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: (650) 676-0442
LICENSING EVALUATOR NAME: Avelina MartinezTELEPHONE: (916) 431-8935
LICENSING EVALUATOR SIGNATURE:

DATE: 11/21/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/21/2023
LIC9099 (FAS) - (06/04)
Page: 5 of 5