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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 392701057
Report Date: 07/05/2024
Date Signed: 07/09/2024 12:09:18 PM


Document Has Been Signed on 07/09/2024 12:09 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 BROOKSIDEFACILITY NUMBER:
392701057
ADMINISTRATOR:TRACY BURKEFACILITY TYPE:
740
ADDRESS:3318 BROOKSIDE ROADTELEPHONE:
(209) 473-1300
CITY:STOCKTONSTATE: CAZIP CODE:
95219
CAPACITY:81CENSUS: 79DATE:
07/05/2024
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
11:14 AM
MET WITH:Tracy BurkeTIME COMPLETED:
02:45 PM
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On 7/5/2024, LPA Johnson arrived unannounced to follow-up on a request for an exception for a prohibited Health Condition.

The facility has retained a Resident (R1) with a prohibited health condition unstageable pressure injury to the right heel.

Home Health agency has been working with R1 from 5/6/2024 to present the facility has third party notes for home health service that have been in place to address a pressure injury to the lower back or tailbone area, right heel and arms. The facility does have orders from the doctor for the 5/6/2024 initial home health services and has recently received notification from the home health RN on 7/2/2024 that R1 has an unstageable pressure injury to the heel and service will be discontinued.

R1 was sent out by the facility to have the injury on the right heel assessed on 6/30/2024. R1 was returned to the facility with no orders to continue home health services for nursing. The injury on the right heel is unstageable and treatment is not viable.


Continued
SUPERVISOR'S NAME: Lisa RiosTELEPHONE: (916) 969-9685
LICENSING EVALUATOR NAME: Albert JohnsonTELEPHONE: (916) 217-1390
LICENSING EVALUATOR SIGNATURE:
DATE: 07/05/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/05/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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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: 07/05/2024
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On 7/3/20204, The facility requested skilled nursing from R1's primary physician. Also noted during the inspection of documents was information about R1's development of a blood blister on the right heel (large hard eschar approximately 1 to 2 inches) about a month ago according to the discharge papers dated 6/30/2024, R1 was prescribed some medication but R1's daughter cannot recall what kind of medication it was. The facility has no record of medication for R1 for treatment of the blood blister. R1 is a self medication administer. The facility did not have the self-medication evaluation form for R1.

The preplacement appraisal dated 4/30 2024, does not include information about treatment plans for the pressure injuries noted on the plan of care from home health dated 5/6/2024.

The facility has requested a exception for R1 dated 7/3/2024.
SUPERVISOR'S NAME: Lisa RiosTELEPHONE: (916) 969-9685
LICENSING EVALUATOR NAME: Albert JohnsonTELEPHONE: (916) 217-1390
LICENSING EVALUATOR SIGNATURE:

DATE: 07/05/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/05/2024
LIC809 (FAS) - (06/04)
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