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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 392701057
Report Date: 03/14/2024
Date Signed: 03/15/2024 04:08:41 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
01/09/2024 and conducted by Evaluator Albert Johnson
PUBLIC
COMPLAINT CONTROL NUMBER: 27-AS-20240109094301
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:
03/14/2024
UNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Nadya RosalesTIME COMPLETED:
03:30 PM
ALLEGATION(S):
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Staff did not seek timely medical care for resident
Staff do not have the required training
Staff did not give resident medication.
INVESTIGATION FINDINGS:
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On 3/14/2024, LPA Johnson arrived unannounce to deliver finding for the above allegations. LPA met with Nadya Rosales.

Allegation: Staff did not seek timely medical care for resident. The allegation is substantiated based on records reviewed and interview with staff. The department discovered through progress notes dated 12/3/2023 that the facility's staff observed R1 on the floor by the bed. R1's family and physician were notified. On 12/6 2023, facility staff called Power of Attorney/ family and informed them that the Primary Care Physician (PCP) wanted to see R1 in the PCP's office. Staff was told by POA/Family, "that's not going to happen. I (POA) will call the doctor to come out and see her." The Doctor never came out to see her and R1 did not go to the doctor office. Continued
Substantiated
Estimated Days of Completion: 0
SUPERVISOR'S NAME: Lisa RiosTELEPHONE: (916) 969-9685
LICENSING EVALUATOR NAME: Albert JohnsonTELEPHONE: (916) 217-1390
LICENSING EVALUATOR SIGNATURE:

DATE: 03/14/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/14/2024
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 6
Control Number 27-AS-20240109094301
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 BROOKSIDE
FACILITY NUMBER: 392701057
VISIT DATE: 03/14/2024
NARRATIVE
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On 12/16/2023, R1 had a witnessed fall at approximately 3:00pm. At 3:45pm, the facility called POA and left a message. The facility's alert charting dated 12/16/23, 8:49pm stated that the POA was contacted and did not want R1 to be transported by ambulance. POA wanted to be updated should anything change. At 11:04pm the facility alert notes confirmed that R1 was sent out to the ER were R1 was admitted at 9:43am and the diagnoses was a rib fracture. Civil penalty assessed.

Allegation: Staff do not have the required training. Based on records reviewed and interviews with staff the facility did not reorder medication prior to R1 running out of medication causing R1 to without two medications for seven days from 9/14/2023 until 9/21/2023. The facility attempted to get the medications for R1 via faxing request to the Primary Care Physician. However the information was not confirmed to be ordered by the PCP until the 9/21/2023. This is a training issues and supports the substantiated allegation.

Allegation: Staff did not give resident medication. Based on records reviewed and interviews with the staff the facility was out of 2 medications for R3 from 9/14/23 to 9/21/23. Substantiated.
SUPERVISOR'S NAME: Lisa RiosTELEPHONE: (916) 969-9685
LICENSING EVALUATOR NAME: Albert JohnsonTELEPHONE: (916) 217-1390
LICENSING EVALUATOR SIGNATURE:

DATE: 03/14/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/14/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 6
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
01/09/2024 and conducted by Evaluator Albert Johnson
COMPLAINT CONTROL NUMBER: 27-AS-20240109094301

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:
03/14/2024
UNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Nadya RosalesTIME COMPLETED:
03:30 PM
ALLEGATION(S):
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9
Staff are serving resident moldy food
Staff handle residents roughly
Residents are not being cleaned properly after changing depends
INVESTIGATION FINDINGS:
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Allegation: Staff are serving resident moldy food, Based on observation, interviews with the residents and resident council minutes. The facility has had issues with the food service regarding temperatures of the meals, items not available or servers in the dining area, however, there was no mention of moldy food. LPA was unable to confirm that the facility serves moldy food. The allegation is unsubstantiated.

Allegation: Staff handle residents roughly. Based on interviews conducted with residents the facility is providing care and support. The residents confirmed that they are provided with assistance during mealtimes, activities time and personal care. There are records of skins tears and the information details falls or unknown origin. The skin tears did not require assistance beyond basic first aid. Unsubstantiated.
Unsubstantiated
Estimated Days of Completion: 0
SUPERVISOR'S NAME: Lisa RiosTELEPHONE: (916) 969-9685
LICENSING EVALUATOR NAME: Albert JohnsonTELEPHONE: (916) 217-1390
LICENSING EVALUATOR SIGNATURE:

DATE: 03/14/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/14/2024
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 6
Control Number 27-AS-20240109094301
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 BROOKSIDE
FACILITY NUMBER: 392701057
VISIT DATE: 03/14/2024
NARRATIVE
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Allegation: Residents are not being cleaned properly after changing depends. Based on interviews with staff and residents along with attempted interviews with residents in memory care the facility is providing care and support. The residents confirmed that they are provided with assistance during mealtimes, activities time and personal care. LPA was unable to confirm that the residents in memory care interviewed understood the questions and were not good witnesses. The allegation is unsubstantiated.

SUPERVISOR'S NAME: Lisa RiosTELEPHONE: (916) 969-9685
LICENSING EVALUATOR NAME: Albert JohnsonTELEPHONE: (916) 217-1390
LICENSING EVALUATOR SIGNATURE:

DATE: 03/14/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/14/2024
LIC9099 (FAS) - (06/04)
Page: 4 of 6
Control Number 27-AS-20240109094301
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 BROOKSIDE
FACILITY NUMBER: 392701057
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/14/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
03/22/2024
Section Cited
CCR
87464(f)(6)
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87464 Basic Services (f) Basic services shall at a minimum include: (6) Arrangements to meet health needs, including arranging transportation, as specified in Section 87465, Incidental Medical and Dental Care Services. This requirement was not met as evidenced by
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Licensee to ensure all staff are up to date and are knowledgeable of the latest PINs and regulations.
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The facility not following the doctors orders and not taking R1 to be checked after the fall on 12/3/23 at the request of the PCP. R1 had another fall at approximately 3 pm and was told by POA not to transport R1 via ambulance. Later in the evening R1 requested to go to the ER and was diagnosed with fractured ribs.
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LPA to receive confirmation of review of the last PIN with staff by POC due date.
Type B
03/22/2024
Section Cited
CCR
87465(a)(1)
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Incidental Medical and Dental Care. (a) plan for incidental medical and dental care shall be developed by each facility (1)The licensee shall arrange, or assist in arranging, for medical and dental care appropriate to the conditions and needs of residents. This requirement is not met as evidenced by:
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Licensee will submit a plan which ensures physician’s are efficiently and effectively notified for any resident care needs. Plan to be submitted to LPA by POC due date.
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 Based on record reviews and interviews, licensee did not ensure physician was efficiently notified for medication order clarification for R1. This poses an immediate 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: Lisa RiosTELEPHONE: (916) 969-9685
LICENSING EVALUATOR NAME: Albert JohnsonTELEPHONE: (916) 217-1390
LICENSING EVALUATOR SIGNATURE:

DATE: 03/14/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/14/2024
LIC9099 (FAS) - (06/04)
Page: 5 of 6
Control Number 27-AS-20240109094301
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 BROOKSIDE
FACILITY NUMBER: 392701057
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/14/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
03/22/2024
Section Cited
CCR
87411(a)
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(a) Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs. In facilities licensed for sixteen or more, sufficient support staff shall be employed to ensure provision of personal assistance and care as required in Section 87608, Postural Supports. Additional staff shall be employed as necessary to perform office work, cooking
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The facility shall conduct a staff in-service training with all staff who distribute medication on proper medication storing and ordering, distribution, training shall include but is not limited to applicable laws in regards to medications. Proof of training shall be sent to Licensing by 03/22/2024
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This requirement was not met as evidenced by R1 being without medication for seven days. This is a potential health and safety risk to resident 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: Lisa RiosTELEPHONE: (916) 969-9685
LICENSING EVALUATOR NAME: Albert JohnsonTELEPHONE: (916) 217-1390
LICENSING EVALUATOR SIGNATURE:

DATE: 03/15/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/15/2024
LIC9099 (FAS) - (06/04)
Page: 6 of 6