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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 392701014
Report Date: 05/12/2022
Date Signed: 05/12/2022 04:33:24 PM


Document Has Been Signed on 05/12/2022 04:33 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
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833



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: DATE:
05/12/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
03:45 PM
MET WITH:Jessica PryorTIME COMPLETED:
04:45 PM
NARRATIVE
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On 5/2/22 LPA Maja Jensen made an unannounced visit to the facility to conduct a case management visit. LPA Jensen met with administrator Jessica Pryor and discussed the purpose of today's visit.

While conducting an interview with resident 1 (R1) he advised he has no way to contact staff if he needs help. LPA Jensen pressed the ALERT button in the bathroom and there was no response from staff.

LPA Jensen interviewed the memory care director and determined that staff used pagers which would notify them if an alert button was pressed but staff had not checked out there pagers at the start of the current shift.

Due to technical issues, LPA Jensen was unable to provide a copy of the report to the Executive Director on 5/2/22 and advised she would return at a later date to provide a copy of the report and appeals rights as well as to follow up on the effectiveness of the call button system. The Executive Director advised that a sign out log would be implemented to assure staff takes pagers at the beginning of the shift.

On 5/12/22 LPA Jensen returned to the facility and conducted an unannounced visit for case management. LPA Jensen again met with Executive Director Jessica Pryor and explained the purpose of the visit. While accompanied by the Executive Director, LPA Jensen tested the alert button in another resident room in the memory care unit. There was no response in excess of ten minutes. It was determined that staff were carrying pagers however the alert was not acknowledged in a timely manner .

As a result of this visit, the following deficiencies were cited, per Title 22 Regulations. The deficiencies were cited on 809-D.

An exit interview was conducted and a copy of this report was given with appeal rights.
SUPERVISOR'S NAME: Liza KingTELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Maja JensenTELEPHONE: 916-639-5584
LICENSING EVALUATOR SIGNATURE:
DATE: 05/02/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/02/2022
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 2


Document Has Been Signed on 05/12/2022 04:33 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 05/12/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
05/12/2022
Section Cited

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(a) In addition to the rights listed in Section 87468.1, Personal Rights of Residents in All Facilities, residents in privately operated residential care facilities for the elderly shall have all of the following personal rights:.....

(4) To care, supervision, and services that meet their individual needs and are delivered by staff that are sufficient in numbers, qualifications, and competency to meet their needs.

This requirement was not as evidenced by:

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Based on LPAs observations during a facility visit on 5/2/22 where there was no response to the alert button and based on a facility visit on 5/12/22 where there was an excessive delay to an alert button test. Qualified and competent staff should have the ability to respond to all call button pager alerts and in a timely manner however this did not occur. This poses a potential health and safety risk 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: Maja JensenTELEPHONE: 916-639-5584
LICENSING EVALUATOR SIGNATURE:
DATE: 05/02/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/02/2022
LIC809 (FAS) - (06/04)
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