392701272-2-27-2025-27-AS-CYAG-DEAMK5-20250227084009

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 392701272
Report Date: 02/21/2025
Date Signed: 02/27/2025 08:40:22 AM

Document Has Been Signed on 02/27/2025 08:40 AM - 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 LODI		FACILITY NUMBER:	392701272
ADMINISTRATOR/ DIRECTOR:	ARMSTRONG, ANDREA		FACILITY TYPE:	740
ADDRESS:	2905 REYNOLDS RANCH PARKWAY		TELEPHONE:	(209) 310-1512
CITY:	LODI	STATE: CA	ZIP CODE:	95240
CAPACITY: 136		CENSUS: 92	DATE:	02/21/2025
TYPE OF VISIT:	Case Management - Legal/Non-compliance	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	10:00 AM
MET WITH:	Andrea Armstrong		TIME VISIT/ INSPECTION COMPLETED:	02:00 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 02/21/2025 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 92 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: Medication Errors Staffing Concerns Reporting Requirements Medication Training 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. Furniture and furnishings were observed to be sufficient and able to meet the needs of the residents at this time.

SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Charlie Yang
LICENSING EVALUATOR SIGNATURE:	DATE: 02/21/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/21/2025

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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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: 02/21/2025

NARRATIVE

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A tour of the memory care unit medication room was conducted. This LPA was met by the current medication technician, Lakena Touch, 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 (10) facility resident files was conducted at this time and noted on the following LIC 858.

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 $250 for a repeat violation on the following LIC 421 FC.

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

Exit Interview

SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Charlie Yang
LICENSING EVALUATOR SIGNATURE:	DATE: 02/21/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/21/2025

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 02/27/2025 08:40 AM - It Cannot Be Edited

Created By: Charlie Yang On 02/21/2025 at 03:25 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: 02/21/2025

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Request Denied Type A 02/22/2025 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.

SUPERVISOR'S NAME:

Liza King

LICENSING EVALUATOR NAME:

Charlie Yang

LICENSING EVALUATOR SIGNATURE:

DATE: 02/21/2025

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/21/2025

LIC809 (FAS) - (06/04)

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