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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 392701057
Report Date: 08/28/2023
Date Signed: 09/13/2023 01:23:56 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
08/07/2023 and conducted by Evaluator Albert Johnson
PUBLIC
COMPLAINT CONTROL NUMBER: 27-AS-20230807125824
FACILITY NAME:OAKMONT OF BROOKSIDEFACILITY NUMBER:
392701057
ADMINISTRATOR:HOLGUIN, PATRICIAFACILITY TYPE:
740
ADDRESS:3318 BROOKSIDE ROADTELEPHONE:
(209) 473-1300
CITY:STOCKTONSTATE: CAZIP CODE:
95219
CAPACITY:81CENSUS: 70DATE:
08/28/2023
UNANNOUNCEDTIME BEGAN:
11:47 AM
MET WITH:Jill WilliamsTIME COMPLETED:
02:00 PM
ALLEGATION(S):
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Staff did not administer resident's medications as prescribed
INVESTIGATION FINDINGS:
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Allegation: Staff did not administer resident's medications as prescribed. Based on records reviewed the facility did not have medications for R1 from1/4/2022 thru 1/13/2022 and 2/6/22 thru 2/8/22. There were two medication not available for R1 on two different occassions. The facility's medication records confirmed that the medications were ordered but not available on-site.

The department has concluded the investigation, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. California Code of Regulations (Title 22, Division 6, Chapter 8) are being cited on the attached LIC-9099D. Failure to correct the deficiency may result in civil penalties. Appeal rights were provided.  An exit interview was conducted.
Substantiated
Estimated Days of Completion: 0
SUPERVISOR'S NAME: Stephenie DoubTELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Albert JohnsonTELEPHONE: (916) 217-1390
LICENSING EVALUATOR SIGNATURE:

DATE: 08/28/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/28/2023
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-20230807125824
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 BROOKSIDE
FACILITY NUMBER: 392701057
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/28/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
08/29/2023
Section Cited
CCR
87465(c)(2)
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87465(c)(2) Incidental Medical and Dental Care. Once ordered by the physician the medication is given according to the physician's directions.
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The Administrator will developed a plan on how the facility will follow the Physician's orders and document correctly when medications are missed. Please send the agenda along with the sign-in sheet for the in-service, by POC date or give a time when the training will take place and send that information to the department
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This requirement is not met as evidenced by: Based on observation and records review, the Licensee did not ensure medications ordered for residents are given as prescribed which poses an immediate health and safety risk to residents in care.
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The facility will also report all incidents of medication errors, missed medication Etc.. to the resident's Primary Care Physician and to the department.
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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: Stephenie DoubTELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Albert JohnsonTELEPHONE: (916) 217-1390
LICENSING EVALUATOR SIGNATURE:

DATE: 08/28/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/28/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 5
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
08/07/2023 and conducted by Evaluator Albert Johnson
PUBLIC
COMPLAINT CONTROL NUMBER: 27-AS-20230807125824

FACILITY NAME:OAKMONT OF BROOKSIDEFACILITY NUMBER:
392701057
ADMINISTRATOR:HOLGUIN, PATRICIAFACILITY TYPE:
740
ADDRESS:3318 BROOKSIDE ROADTELEPHONE:
(209) 473-1300
CITY:STOCKTONSTATE: CAZIP CODE:
95219
CAPACITY:81CENSUS: 70DATE:
08/28/2023
UNANNOUNCEDTIME BEGAN:
11:47 AM
MET WITH:Jill WilliamsTIME COMPLETED:
02:00 PM
ALLEGATION(S):
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Staff did not answer resident's call button in a timely manner
INVESTIGATION FINDINGS:
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Allegation: Staff did not answer resident's call button in a timely manner. During a file review, there were supporting documents to confirm care staff were responding to call buttons. LPA was unable to determine if the calls were answered in a timely manner. The times varied and it appears that the request for services were answered. R1 as a result of the information provided did not experience any ill-effects from the time of responds provided to the call buttons.

Due to the above noted information, although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, and therefore the allegations are unsubstantiated. There were no deficiencies cited at this visit. An exit Interview was conducted and a copy of the report was given to the facility.
Unsubstantiated
Estimated Days of Completion: 0
SUPERVISOR'S NAME: Stephenie DoubTELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Albert JohnsonTELEPHONE: (916) 217-1390
LICENSING EVALUATOR SIGNATURE:

DATE: 08/28/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/28/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.
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
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
08/07/2023 and conducted by Evaluator Albert Johnson
PUBLIC
COMPLAINT CONTROL NUMBER: 27-AS-20230807125824

FACILITY NAME:OAKMONT OF BROOKSIDEFACILITY NUMBER:
392701057
ADMINISTRATOR:HOLGUIN, PATRICIAFACILITY TYPE:
740
ADDRESS:3318 BROOKSIDE ROADTELEPHONE:
(209) 473-1300
CITY:STOCKTONSTATE: CAZIP CODE:
95219
CAPACITY:81CENSUS: 70DATE:
08/28/2023
UNANNOUNCEDTIME BEGAN:
11:47 AM
MET WITH:Jill WilliamsTIME COMPLETED:
02:00 PM
ALLEGATION(S):
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Staff did not ensure resident had portable oxygen for appointment
Staff did not maintain the facility in clean and sanitary condition
INVESTIGATION FINDINGS:
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Allegation: Staff did not ensure resident had portable oxygen for appointment. Based on records reviewed the facility did send R1 out to the ER with the portable oxygen. The information was included on the correspondence sent to the doctor and noted on the medical information reviewed for R1.

Allegation: Staff did not maintain the facility in clean and sanitary condition.
Based on multiple visits and observation during these visits the facility is well kept. The facility is clean, safe, sanitary and in good repair during my visits. The facility has and procedures for the safety and the well-being of residents, employees and visitors.

Continued
Unfounded
Estimated Days of Completion: 0
SUPERVISOR'S NAME: Stephenie DoubTELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Albert JohnsonTELEPHONE: (916) 217-1390
LICENSING EVALUATOR SIGNATURE:

DATE: 08/28/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/28/2023
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-20230807125824
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 BROOKSIDE
FACILITY NUMBER: 392701057
VISIT DATE: 08/28/2023
NARRATIVE
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LPA observed floor surfaces in bath, laundry and kitchen areas were maintained, clean, sanitary, and odorless condition. LPA also observed and experienced a comfortable temperature for residents.

“This agency has investigated the complaints. We have found that the complaint was unfounded, meaning that the allegation was false, could not have happened and/or is without a reasonable basis. We have therefore dismissed the complaint.”
SUPERVISOR'S NAME: Stephenie DoubTELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Albert JohnsonTELEPHONE: (916) 217-1390
LICENSING EVALUATOR SIGNATURE:

DATE: 08/28/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/28/2023
LIC9099 (FAS) - (06/04)
Page: 5 of 5