392701057-5-13-2024-27-AS-AJON-D58UPJ-20240513154538

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 392701057
Report Date: 05/13/2024
Date Signed: 05/13/2024 03:45:47 PM

Document Has Been Signed on 05/13/2024 03:45 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
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME:	OAKMONT OF BROOKSIDE		FACILITY NUMBER:	392701057
ADMINISTRATOR:	TRACY BURKE		FACILITY TYPE:	740
ADDRESS:	3318 BROOKSIDE ROAD		TELEPHONE:	(209) 473-1300
CITY:	STOCKTON	STATE: CA	ZIP CODE:	95219
CAPACITY:	81	CENSUS: 80	DATE:	05/13/2024
TYPE OF VISIT:	Case Management - Incident	UNANNOUNCED	TIME BEGAN:	01:00 PM
MET WITH:	Tracy Burke		TIME COMPLETED:	02:15 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	On 5/10/2024 Licensing Program Analyst (LPA) Albert Johnson conducted an unannounced case management visit to the facility for incidents of unwitnessed and witnessed falls. R1 had a witnessed fall on 5/1/2024, R1 was taken to the ER and was diagnosed with a fracture of the Tibial Plateau. R1 returned to the facility on hospice. R1 service plan dated 4/16/2024 confirmed that R1 was a two person assist with transferring. Based on the incident report dated 5/7/2024, R1 was transferring from the recliner chair to the wheelchair and fell. R1 was being assisted with transferring by S1, the facility did not have as assessed a second person to assist with the transfer and as a result R1 fell and sustained a fracture. R2 was sent out on 4/13/2024 for evaluation from feeling sleepy and lethargic. During the review of the file the department discovered that R2 had a fall on 4/15/2024 witnessed by R2's wife and reported to the facility. R2 was sent out to the ER at St. Joseph's hospital. The discharge summary listed the chief complaint as a fall yesterday(4/15/2024) w/subdural hemorrhage. R2 was discharged and scheduled to see the primary care physician on 5/8/2024. R2 did not return to the facility after April 15th 2024. Continued

SUPERVISOR'S NAME: Lisa Rios	TELEPHONE: (916) 969-9685
LICENSING EVALUATOR NAME: Albert Johnson	TELEPHONE: (916) 217-1390
LICENSING EVALUATOR SIGNATURE:	DATE: 05/13/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/13/2024

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 3

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 05/13/2024

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

R3 had an unwitnessed fall and was sent out to San Joaquin General ER. R3 was diagnosed with a Hematoma to the forehead. R3 was to follow-up with primary care physician. During the review of the file the department observed an outdated
Physician's report. (LIC 602 4/27/2024).

Deficiencies are cited on 809-D, per Title 22 Regulations, Division 6.
At the time of the complaint visit, an immediate civil penalty of $500 shall be assessed for a violation of California Code of Regulations Section 87464(f)(1). The licensee was informed that an enhanced civil penalty (ECP) was pending review and may be assessed according to Health and Safety Code 1569.49(f). Once civil penalty assessments have been determined, an LPA will return at a future date to assess the civil penalties.

Exit interview was conducted. Appeal rights given.

SUPERVISOR'S NAME: Lisa Rios	TELEPHONE: (916) 969-9685
LICENSING EVALUATOR NAME: Albert Johnson	TELEPHONE: (916) 217-1390
LICENSING EVALUATOR SIGNATURE:	DATE: 05/13/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/13/2024

LIC809 (FAS) - (06/04)

Page: 2 of 3

Document Has Been Signed on 05/13/2024 03:45 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
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: 05/13/2024

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 05/15/2024 Section Cited CCR 87464(f)(1)	1 2 3 4 5 6 7	87464 (f)(1) Basic services care and supervision as defined in Section 87101(c)(3) and Health and Safety Code section 1569.2(c). This requirement is not met as evidence by:	1 2 3 4 5 6 7	Licensee agrees to submit a plan of correction to LPA by 5/15/2024 on how the facility will be in compliance with regulation 87464(f)(1) at all times.
	8 9 10 11 12 13 14	Based on the department's findings, the facility did not provide adequate care and supervision including a two person assist which resulted in R1 sustaining a fracture from a fall while transferring. This posed an immediate health and safety risk to R1.	8 9 10 11 12 13 14	Civil penalty assessed
Type B 05/17/2024 Section Cited CCR87705(c)(5)	1 2 3 4 5 6 7	87705(c)(5)Care of Persons with Dementia Licensees who accept and retain residents with dementia shall ensure that each resident with dementia has an annual medical assessment and a reappraisal done at least annually	1 2 3 4 5 6 7	All residents diagnosed with dementia will be scheduled with their responsible physician and be assessed for any changes to their needs with an updated LIC 602.
	8 9 10 11 12 13 14	This requirement was not met based on records reviewed, The department observed R3 with an outdated LIC 602/ Physician report expired. This poses a potential health and safety risk to residents in care.	8 9 10 11 12 13 14	Statement of correction, with copy of updated LIC 602, to be completed and submitted into CCL by the due date

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: Albert Johnson	TELEPHONE: (916) 217-1390
LICENSING EVALUATOR SIGNATURE:	DATE: 05/10/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/10/2024

LIC809 (FAS) - (06/04)

Page: 3 of 3