<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 392701272
Report Date: 06/19/2025
Date Signed: 06/20/2025 05:06:20 PM

Document Has Been Signed on 06/20/2025 05:06 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: 97DATE:
06/19/2025
TYPE OF VISIT:Case Management - Legal/Non-complianceUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
03:30 PM
MET WITH:Andrea ArmstrongTIME VISIT/
INSPECTION COMPLETED:
06:00 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
Unannounced case management visit made out to this facility on 06/19/2025 by Licensing Program Analyst (LPA) Charlie Yang who was met by the facility designated Administrator, Andrea Armstrong, at this time. A brief interview was conducted with the facility designated Administrator at this time.
Current census was 97 residents, of which 29, resided in the memory care unit also referred to as Traditions.
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
  3. Staffing Concerns
  5. Reporting Requirements
  7. Medication Training
  9. Facility Polices Regarding: Assessments, Monitoring of Residents, Change in Condition, Medication Errors
A tour of the memory care unit, Traditions, was conducted.
A review of the living areas, dining area, and all other areas intended for resident use was conducted.
NAME OF LICENSING PROGRAM MANAGER: Liza King
NAME OF LICENSING PROGRAM ANALYST: Charlie Yang
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 06/19/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/19/2025
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 5
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)
Page: 2 of 5
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: 06/19/2025
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
Furniture and furnishings were observed to be sufficient and able to meet the needs of the residents at this time.
A tour of the assisted living medication room was conducted. This LPA was met by the current medication technician on duty who was interviewed at this time.
Policies and procedures involving the handling, dispensing, and documentation of the resident medications were discussed with the present medication technician at this time.
A review of the facility Medication Administration Record was conducted. It was observed that this facility currently employed an electronic Medication Administration Record (E-MAR) system as well as documenting on forms and documents as well.
A review of the facility narcotics policies and procedures was conducted. In addition, a review of the Controlled Medication Administration Record for the resident narcotics was conducted.
It was observed by this LPA that on 05/05/2025, 05/17/2025, and 06/01/2025 that there were more than the required (3) entries for the narcotics count which were performed by the oncoming shift medication technician and the off going shift medication technician. This was observed to be evident on 05/05/2025 which had (4) entries and 05/17/2025 had a total of (5) entries made on the narcotics count log. On 06/01/2025, it was observed by this LPA that there were only (2) entries made for that day for the AM and Evening shifts and the Night shift did not have an entry for either the oncoming or off going medication technicians.
A tour of the memory care unit medication room was conducted. This LPA was met by the current medication technician on duty who was interviewed at this time.
Policies and procedures involving the handling, dispensing, and documentation of the resident medications were discussed with the present medication technician at this time.
A review of the facility Medication Administration Record was conducted. It was observed that this facility currently employed an electronic Medication Administration Record (E-MAR) system as well as documenting on forms and documents as well.
A review of the facility narcotics policies and procedures was conducted. In addition, a review of the Controlled Medication Administration Record for the resident narcotics was conducted.
A review of the assigned tasks and duties for caregivers to complete for all three shifts (AM, PM, NOC or referred to as Day, Evening, and Night) was reviewed for proper documentation and notation at this time.
It was observed by this LPA that there were a total of (7) days ranging from 04/01/2025 through 06/01/2025 where there were not the required (3) entries for AM, PM, and the NOC shift or referred to as the Day, Evening, and Night shifts from this facility.
NAME OF LICENSING PROGRAM MANAGER: Liza King
NAME OF LICENSING PROGRAM ANALYST: Charlie Yang
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 06/19/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/19/2025
LIC809 (FAS) - (06/04)
Page: 3 of 5
Document Has Been Signed on 06/20/2025 05:06 PM - It Cannot Be Edited


Created By: Charlie Yang On 06/19/2025 at 05:10 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: OAKMONT OF LODI
FACILITY NUMBER: 392701272

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/19/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Request Denied
Type A
06/20/2025
Section Cited
CCR
87465(a)(4)

1
2
3
4
5
6
7
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 evidenced by:
Based on a review of the facility
1
2
3
4
5
6
7
The facility designated Administrator stated that an audit of the facility medication administration records will be conducted for both the Assisted Living and Memory Care (Traditions) components. Training, for no less than (1) hour in duration, will be conducted on the topic of proper handling,
8
9
10
11
12
13
14
medication administration record (MAR) and Controlled Medication Administration Record, it was observed that required names/initials for narcotics counts were missing, dates were omitted or incorrect, and medications were not dispensed as prescribed which poses/posed an immediate risk to the health, safety, and personal rights of the residents in care.
8
9
10
11
12
13
14
dispensing, and documentation of all facility resident medications. A statement of correction, along with proof of updated medication training, will be completed and submitted into CCL by the due date. Proof of training will include name of trainer, training topic(s), and list of attendees.

1
2
3
4
5
6
7
1
2
3
4
5
6
7

1
2
3
4
5
6
7
1
2
3
4
5
6
7
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Liza King
NAME OF LICENSING PROGRAM MANAGER:
Charlie Yang
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 06/19/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/19/2025


LIC809 (FAS) - (06/04)
Page: 4 of 5
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: 06/19/2025
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
It was observed that on 04/27, 04/28, 05/05, 05/12, 05/19, and 05/21/2025 there were only (2) narcotics counts made for that day missing one from either the Day, Evening, or Night shifts.
It was observed that on 04/26/2025, there were a total of (4) entries made for that day with duplicate entries filled in by the responsible staff persons.
In addition, the Staff Assignments by Month by Responsible Party/Resident Name for the month of June 2025 was reviewed by this LPA. It was observed that entries were made into this binder for future dates by the care staff when the assigned duties had not even been completed yet.
It was also observed that the caregivers did not properly fill out and initial into this binder when the assigned tasks had been completed for that corresponding day.

The following deficiencies were observed and cited on the following LIC 809-D pursuant to Title 22 Rules and Regulations, Health and Safety Codes.

A civil penalty was assessed in the amount of $1000 for a repeat violation on the following LIC 421 IM.

Appeal Rights were printed and a copy was given to the facility designated Administrator Andrea Armstrong at this time.

Exit Interview
NAME OF LICENSING PROGRAM MANAGER: Liza King
NAME OF LICENSING PROGRAM ANALYST: Charlie Yang
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 06/19/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/19/2025
LIC809 (FAS) - (06/04)
Page: 5 of 5