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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 392701272
Report Date: 01/17/2024
Date Signed: 01/17/2024 01:51:17 PM


Document Has Been Signed on 01/17/2024 01:51 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 LODIFACILITY NUMBER:
392701272
ADMINISTRATOR:ARMSTRONG, ANDREAFACILITY TYPE:
740
ADDRESS:2905 REYNOLDS RANCH PARKWAYTELEPHONE:
(209) 310-1512
CITY:LODISTATE: CAZIP CODE:
95240
CAPACITY:136CENSUS: 85DATE:
01/17/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
09:15 AM
MET WITH:Andrea ArmstrongTIME COMPLETED:
02:15 PM
NARRATIVE
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An unannounced case management visit was conducted by the Licensing Program Analyst (LPA) Avelina Martinez on 01/17/2024 at 9:15 AM. LPA Martinez met with Andrea Armstrong and explain the purpose of the visit.

The purpose of the visit is to follow up on learned deficiencies during complaint investigation 27-AS-20231114094113. Based to the investigation, the following deficiencies were learned: reporting requirements and incidental and medical.

During 27-AS-20231114094113 investigation, it was revealed on November 24, 2023 at the AM shift, resident 1 (R1) was missing one 5-325 MG Hydrocodone tablet. An incident report was not provided to CCLD. The Hydrocodone 5-325 MG medication prescription was received on 11/12/2023 with 112 tablets. The first Hydrocodone tablet administered was on 11/12/2023 at 6:00 PM. The last Hydrocodone tablet administered was on 12/10/2023 at 7:00 AM. The facility requested an emergency supply of Hydrocodone on 12/10/2023 at 3:24 PM. R1's December 2023 Medication Administration Records (MAR) reported Acetaminophen 500 MG was administered on 12/10/2023 at 6:22 PM for pain. On 12/11/2023 at 7:26 AM Acetaminophen 500 MG was administered for pain, however, notes indicate R1 was still in a lot of pain. It was learned Hydrocodone was delivered on 12/11/2023, and the first Hydrocodone tablet administered was on 12/11/2023 at 6:00 PM. As a result, the facility did not follow Hydrocodone prescription orders and did not assist R1 with self administered medications as needed. Additionally, According to R1's November 2023 MAR, the following medications were not administered on November 16, 2023: Anastrozole 1 MG, Atorvastatin 10 MG, Docusate Sodium 100 MG, Hydrocodone-Acetamin 5-325 MG, Lisinopril 20 MG, and Metoprolol Tartrate 50 MG. Moreover, on November 23, 2023 Anastrozole 1 MG and Lisinopril 20 MG were not administered. In addition, the facility self reported to CCLD that staff administered the wrong medication to resident 2 (R2) on December 24, 2023. On December 24, 2023, resident 3 (R3) was administered the wrong medication, which was reported to CCLD by the facility. Continued...

SUPERVISOR'S NAME: Liza KingTELEPHONE: (650) 676-0442
LICENSING EVALUATOR NAME: Avelina MartinezTELEPHONE: (916) 431-8935
LICENSING EVALUATOR SIGNATURE:
DATE: 01/17/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/17/2024
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 4


Document Has Been Signed on 01/17/2024 01:51 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 LODI
FACILITY NUMBER: 392701272

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/17/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
01/17/2024
Section Cited
CCR
87465(a)(4)

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87465(a)(4) Incidental Medical and Dental Care: A plan for incidental medical and dental care shall be developed by each facility...The licensee shall assist residents with self-administered medications as needed. This requirement was not met as evidence by:
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The Administrator reported Medication Incidental and medical training was conducted on

POC was cleared at time of visit.
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Based on file review and interviews, The licensee did not ensure staff were administering R1, R2, and R3's medication as required and did not ensure staff were administering the correct medication to R2 and R3. This posed an immediate health and safety risk to R1, R2, and R3.
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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: (650) 676-0442
LICENSING EVALUATOR NAME: Avelina MartinezTELEPHONE: (916) 431-8935
LICENSING EVALUATOR SIGNATURE:
DATE: 01/17/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/17/2024
LIC809 (FAS) - (06/04)
Page: 2 of 4


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 LODI
FACILITY NUMBER: 392701272
VISIT DATE: 01/17/2024
NARRATIVE
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As a result, facility staff did not assist residents with self administered medications as needed.

Due to this case management, The following deficiencies were observed and cited from the California Code of Regulations, Title 22, and California Health and Safety Code. An exit interview was conducted, and a copy of the 809 report and appeal rights were given to the facility.

SUPERVISOR'S NAME: Liza KingTELEPHONE: (650) 676-0442
LICENSING EVALUATOR NAME: Avelina MartinezTELEPHONE: (916) 431-8935
LICENSING EVALUATOR SIGNATURE:

DATE: 01/17/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/17/2024
LIC809 (FAS) - (06/04)
Page: 4 of 4
Document Has Been Signed on 01/17/2024 01:51 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 LODI
FACILITY NUMBER: 392701272

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/17/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
01/17/2024
Section Cited
CCR
87465(6)

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87465(6)Incidental Medical and Dental Care The licensee shall be responsible for assuring that a record of centrally stored prescription medications for each resident is maintained for at least one year... This requirement was not met as evidence by: Based on interviews and file reviews,
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The Administrator reported Incidental and medical training was conducted on 01/05/2023.

POC was cleared at time of visit.
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The Licensee did not ensure MARs were being maintained for R1, R2, and R3. This posed a potential health and safety risk to residents in care.
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Type B
01/17/2024
Section Cited
CCR87211(a)(1)(D)

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87211(a)(1)(D)Reporting Requirements each licensee shall furnish to the licensing agency such reports...Any incident which threatens the welfare, safety or health of any resident, such as psychological abuse of a resident by staff or other residents, or unexplained absence of any resident. This requirement
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The Administrator reported Reporting training was conducted on 01/17/2023.

POC was cleared at time of visit.
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was not met as evidence by: based on interviews and file review the facility did not submit incident reports in regards to medication errors. This posed a potential health and safety risk to R1.
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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: (650) 676-0442
LICENSING EVALUATOR NAME: Avelina MartinezTELEPHONE: (916) 431-8935
LICENSING EVALUATOR SIGNATURE:
DATE: 01/17/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/17/2024
LIC809 (FAS) - (06/04)
Page: 3 of 4