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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 392701272
Report Date: 07/25/2024
Date Signed: 07/25/2024 02:41:29 PM

Document Has Been Signed on 07/25/2024 02:41 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: 98DATE:
07/25/2024
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:00 AM
MET WITH:Andrea ArmstrongTIME VISIT/
INSPECTION COMPLETED:
03:15 PM
NARRATIVE
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Licensing Program Analyst (LPA) Avelina Martinez arrived at facility unannounced to conduct a case management visit on 07/25/2024 at 9:00 AM. LPA Martinez met with Andrea Armstrong and explained the purpose of the visit.

The purpose of the visit today is to conduct a quarterly visit. LPA Martinez followed up with the following:
  1. Staffing Concerns: Job Fairs conducted and continuos hiring.
  2. Medication Errors: A medication error was reported to Community Care Licensing Department (CCLD) by the facility.
  3. Medication Audit: A medication audit was completed on July 18, 2024.
  4. Reporting Requirements: The Department has received incident reports from the facility.
  5. Medication Training: June 12, 2024 and July 15, 2024.
  6. Facility Polices Regarding: Assessments, Monitoring of residents, Change in condition, Medication errors. Polices provided to CCLD.

Quarterly Visit Review:
Medication Error: Resident (R1) was given the wrong Metoprolol SUCC ER dosage. Per facility medication error communication note, R1 was administered the wrong dosage from June 06, 2024 to July 09, 2024. During the error medication review, it was learned R1 Medication Administrator Records (MAR) were not maintained. The February and May MAR had missing staff administration signatures: February 07, 2024-Metoprolo; May 23 and 25, 2024. LPA Martinez reviewed the MARs' caregiver notes for the missing administration signatures information, and there were no notes. LPA Martinez also requested new medication orders and discontinued medication orders for Metoprolol. The requested medication orders were not provided during today's visit. LPA Martinez was informed by staff that the orders would need to be requested from pharmacy. Continued...
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Avelina Martinez
LICENSING EVALUATOR SIGNATURE: DATE: 07/25/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/25/2024
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 LODI
FACILITY NUMBER: 392701272
VISIT DATE: 07/25/2024
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Facility staff will email medication orders to LPA Martinez by August 04, 2024. Because you have been cited for repeating the same violation within 12 months (California Code of Regulations Section 87465(a)(4)), a civil penalty in the amount of $1,000.00 shall be assessed 07/25/2024. Please refer to LIC 421IM form for additional information.

Reassessments: LPA Martinez reviewed resident 2 (R2) assessments and health condition changes. LPA Martinez reviewed a March 21, 2024 pre-assessment and a March 21, 2024 individualized service plan (ISP). The pre assessment- skin care section stated, "resident has no skin impairment." The healing wounds/bedsores section states, "requires staff monitoring and assistance with care of healing wound/pressure injuries from licensed nurse. The ISP skin care section states, "resident has no skin impairment." Healing wound section states, "Resident has home health for left leg...left leg with redness and flaky skin with scabs...no open wounds."

LPA Martinez reviewed a medical visit summary dated April 09, 2024. This summary indicated R1 had a right leg wound and required wound care. Medical summary visit also included physician orders: wear compression sock during the day; keep wound clean and dry; elevate legs whenever possible; water consumption 1.7 liters per day; and lower salt intake. LPA Martinez did not observer an updated April 2024 assessment to implement the April 09, 2024 physician orders and to include home health care. Also, the assessment did not clarify if R1 was diagnosed with a pressure injuries or wounds.

LPA Martinez reviewed an ISP dated May 01, 2024. The skin care section states, "resident has no skin impairment." Healing wound section states, "resident has no healing wounds or pressure injuries." The May 01, 2024 ISP does not included R2's April 09, 2024 physician orders: wear compression sock during the day; keep wound clean and dry; elevate legs whenever possible; water consumption 1.7 liters per day; and lower salt intake. The assessment does not include if wounds have healed and does not indicate if R2's is receiving skin integrity observation/monitoring. Based on the facility file review, R2's assessment plan was not being updated and maintained.

As a result, of today's quarterly visit, deficiencies can be found on the 809D page. An exit was conducted, and a copy of the 809 report, 809D Pages
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Avelina Martinez
LICENSING EVALUATOR SIGNATURE:

DATE: 07/25/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/25/2024
LIC809 (FAS) - (06/04)
Page: 4 of 4
Document Has Been Signed on 07/25/2024 02:41 PM - It Cannot Be Edited


Created By: Avelina Martinez On 07/25/2024 at 12:04 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: 07/25/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Request Denied
Type A
07/25/2024
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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Facility Staff has conducted medication training on July 15 and will conduct a medication training by August 15. LPA Martinez was provided medication training materials on 07/25/2024. POC cleared at visit.
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Based on interviews and file review: The Licensee did not ensure R1 was administered the correct Metoprolol dosage from 06/06/24 to 07/09/2024. This posed an immediate health and safety risk to R1.
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Type B
08/08/2024
Section Cited
CCR87465(a)(6)

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87465(a)(6) Incidental Medical and Dental Care: A plan for incidental medical and dental care shall be developed by each facility.When requested by the prescribing physician or the Department, a record of dosages of medications which are centrally stored shall be maintained by the facility.
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Facility Staff has conducted medication training on July 15 and will conduct a medication training by August 15. LPA Martinez was provided medication training materials on 07/25/2024. POC cleared at visit
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This requirement was not met as evidence by:Based on file review: The Feb & May MARs provided to LPA Martinez by Facility showed staff did not sign off on MARs for medication Metoprolol on May 23 and 25 & Feb 07 2024. 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 King
LICENSING EVALUATOR NAME:Avelina Martinez
LICENSING EVALUATOR SIGNATURE:
DATE: 07/25/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/25/2024


LIC809 (FAS) - (06/04)
Page: 2 of 4
Document Has Been Signed on 07/25/2024 02:41 PM - It Cannot Be Edited


Created By: Avelina Martinez On 07/25/2024 at 01:42 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: 07/25/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/25/2024
Section Cited
CCR
87463(a)

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87463(a) Reappraisals: The pre-admission appraisal shall be updated, in writing as frequently as necessary to note significant changes and to keep the appraisal accurate. The reappraisals shall document changes in the resident's physical, medical, mental, and social condition. This requirement was not met
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Facility will conduct regular assessment audit for the next two months (September 25, 2024). Email LPA Martinez a bi-weekly update on audits. Email R2's assessment to LPA Martinez by August 09, 2024
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as evidence by: Based on interviews and file reviews, R2's assessments were not maintained and did not contain significant health changes and the assessments provided to LPA Martinez were not signed by RP, R2, or staff. This posed an immediate health and safety risk to R2.
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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 King
LICENSING EVALUATOR NAME:Avelina Martinez
LICENSING EVALUATOR SIGNATURE:
DATE: 07/25/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/25/2024


LIC809 (FAS) - (06/04)
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