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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 392701272
Report Date: 09/25/2025
Date Signed: 09/25/2025 04:21:08 PM

Document Has Been Signed on 09/25/2025 04:21 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/
DIRECTOR:		ARMSTRONG, ANDREAFACILITY TYPE:
740
ADDRESS:2905 REYNOLDS RANCH PARKWAYTELEPHONE:
(209) 310-1512
CITY:LODISTATE: CAZIP CODE:
95240
CAPACITY: 136CENSUS: 92DATE:
09/25/2025
TYPE OF VISIT:Case Management - Legal/Non-complianceUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:30 AM
MET WITH:Andrea ArmstrongTIME VISIT/
INSPECTION COMPLETED:
04:00 PM
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Unannounced case management visit made out to this facility today by Licensing Program Analyst (LPA) Charlie Yang and Licensing Program Manager (LPM) Liza King, who were met by the facility Health and Wellness Director Afifa Kahn and Memory Care Director Jocelyn Ning and the purpose of the visit was explained. The designated Administrator Andrea Armstrong arrived at 9am.
Current census was 92 residents, of which 27 resided in the memory care unit also referred to as Traditions. Currently there are 8 persons receiving hospice care, no residents require a hoyer lift.
The purpose of this case management visit was to conduct a quarterly visit as outlined from the Non Compliance Conference held on 03/25/2024 and the requirement to have increased monitoring at that time.
The focus of this quarterly visit was to review the following items that were initially brought forth on 03/25/2024:
  1. Medication Errors addressed in report
  3. Staffing Concerns addressed in report
  5. Reporting Requirements addressed in report
  7. Medication Training past 3 months has been sent via email to Charlie.Yang@dss.ca.gov for review
  9. Facility Polices Regarding: Assessments, Monitoring of Residents, Change in Condition, Medication Errors - any inservices related to the above over the pst 3 months to be sent via email to Charlie.Yang@dss.ca.gov for review cont.
NAME OF LICENSING PROGRAM MANAGER: Krystall Moore
NAME OF LICENSING PROGRAM ANALYST: Liza King
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 09/25/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/25/2025
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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California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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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 LODI
FACILITY NUMBER: 392701272
VISIT DATE: 09/25/2025
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A tour of the Traditions neighborhood was conducted. LPM King observed breakfast meal service consisting of eggs, bacon, sausage, pancakes and cereal. Residents appeared groomed and ready for the day. LPM verified doors that required to be secured were, the area appeared clean with no presense of odor. A tour of all hospice rooms in the Traditions area was conducted as well as well as 4 additional rooms.
Rooms were clean without clutter or odor, no toxins were present. Staff consisted of a Memory Care Director, three caregivers, one housekeeper and one medtech in the Traditions area upon arrival. Interview confirmed this is usual staffing except on weekends when there are one additional caregiver on each shift in case of call offs. A copy of the Aug schedule and hours worked log was requested for review. The schedule shows 3 care givers and 1 medtech scheduled both AM and PM shift and 1 caregiver and 1 medtech for the overnight shift. According to interview with staff there are 10 residents in the Traditions area that require 2 person assistance. According to interview with the Administrator although this is a preference of staff there are 4 careplans that require 2 person assistance, the Health and Wellness Director confirmed this. Staff schedule for the month of Aug was reviewed. Staff hours worked during the month of Aug were reviewed. On one of four days reviewed during the month of Aug care staff were 2 for am and 2 for pm shifts. Admin reported that when there is a shortage of care staff then the Memory Care Director is to provide assistance with care on the floor. During the visit, the care logs were not verified to show if the MCD provided care. This will be looked at on a future visit. Based on the staff schedule there is one CG on NOCs and one Med Tech assigned to the Traditions area. Per interview with the Admin the caregiver from the Asissted Living side is called to the Traditions area to assist when needed. Additionally, the MedTech is available to assist with care. Lunch meal service was observed.

The shower log was reviewed for the current month which showed one missed shower (resident refused). ADL logs were reviewed for AM, PM and overnight shifts for the month of September which document dressing, bathing, grooming toileting and transfer assistance all being provided.

cont.





NAME OF LICENSING PROGRAM MANAGER: Krystall Moore
NAME OF LICENSING PROGRAM ANALYST: Liza King
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 09/25/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/25/2025
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 LODI
FACILITY NUMBER: 392701272
VISIT DATE: 09/25/2025
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Four resident files were reviewed as a result of incident reports received in the Regional Office (RO). R1 sustained 5 falls over the past 3 months. The RO received 2 IRs for the month of September. Fax conformation was provided for falls that occurred during July and Aug. All care plans were updated. R2 remains out of the community and further follow up is necessary. For R3 the RO is requesting the facility obtain the Death Certificate and forward it to the RO. Additional follow up may be necessary. IR received in the RO for the incident. R4 5 IRs related to falls were provided while at the facility for the months of July, Aug, and September. During a file review the LPM revealed 3 additional falls during the month of Aug. According to the Admin falls without injury or ER visit do not result in an incident report being submitted to the RO. Based on documentation the resident has fallen 8 times over the review period. The Care Plan was updated one time dated 08/25/2025. Per conversation with Admin no additional interventions are needed at this time. The RO received one incident report. Fax confirmation was provided at todays visit for the additional IRs.

LPM reviewed the Physicians orders and MARS for the months of July, Aug and September for four residents in Traditions (R6, R7, R8, R9). Prn medication provided and effectiveness were documented. R6 all medications were signed off. R7 medications were not signed of for the PM on 08/02/2025, incident was reported to the RO, no other missed medications. R8 PM medications missed on 08/02/25 and reported to the RO. Additionally, melatonin missed on 08/03 and 08/04, breathing treatment was missed on 08/16 due to facility awaiting Rx to be delivered. Again, this occurred on 09/06, 9/23, 09/24 and 09/25; medications pending refill delivery. R9 no missed medications. Technical Assistance was provided as 3 of 4 resident Centrally Stored logs were not completed. LPM reviewed Controlled Substance logs which were complete, 12 bottles pulled and compared to the Centrally stored log and 5 counts were completed with no concerns noted. A follow up visit will occur at a later date to review Centrally Stored logs again.

Citations were issued today in relation to a complaint received regarding mismanagement of medications. The findings from todays visit are being incorporated into that finding. NO citations are being issued as a result of this visit. An Exit interview was conducted with Andrea Armstrong, Afifa Kahn and Jocelyn Ning and a copy of the report was provided.

NAME OF LICENSING PROGRAM MANAGER: Krystall Moore
NAME OF LICENSING PROGRAM ANALYST: Liza King
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 09/25/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/25/2025
LIC809 (FAS) - (06/04)
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