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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 392701272
Report Date: 04/27/2026
Date Signed: 04/27/2026 03:49:49 PM

Document Has Been Signed on 04/27/2026 03:49 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: 86DATE:
04/27/2026
TYPE OF VISIT:Case Management - Legal/Non-complianceUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:15 AM
MET WITH:Andrea Armstrong TIME VISIT/
INSPECTION COMPLETED:
04:15 PM
NARRATIVE
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On 04/27/2026, Licensing Program Analyst (LPA) Arielle Pascua arrived unannounced to this facility to conduct a case management visit. LPA Pascua was greeted by Facility Designated Administrator (FDA), Andrea Armstrong and explained the purpose of the visit.
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
  2. Staffing Concerns
  3. Reporting Requirements
  4. Medication Training
  5. Facility Polices Regarding: Assessments, Monitoring of Residents, Change in Condition, Medication Errors.
During today's visit, LPA Pascua conducted a tour of the Assisted Living, kitchen, outside areas, and memory care unit. It was learned during the course of this tour that this facility has 3 caregivers, 1 medication technician, and 1 activity director in each memory care and assisted living areas. In addition, the assisted living units have an additional activities aid and facility driver.
LPA Pascua reviewed the Medication rooms in both the Assisted Living and Memory Care areas. Policies and procedures involving the handling, dispensing, and documentation of the resident medications were discussed with the present medication technician at this time.
NAME OF LICENSING PROGRAM MANAGER: Lisa Rios
NAME OF LICENSING PROGRAM ANALYST: Arielle Pascua
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 04/27/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/27/2026
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: 04/27/2026
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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 PRN and daily logs have been completed and dated by the Medication Technician as of this date, 04/27/2026. In addition, medication has been logged and accounted for during medication pass at 1:12pm.

A review of the assigned tasks and duties for caregivers to complete for all three shifts for memory care and assisted living(AM, PM, NOC or referred to as Day, Evening, and Night) was reviewed for proper documentation and notation at this time. It was observed that the facility staff did not properly fill out and initial into this binder when the assigned tasks had been completed for book #1 and Book#2. Book #1 did not have initials in this binder for 04/15 NOC shift, 04/20 AM shift, and 04/21 NOC shift. Book #2 did not have initials for 04/15 PM shift and 04/21 NOC Shift. A review of the memory care logs were conducted.
In addition, the Staff Assignments by Month by Responsible Party/Resident Name for the month of April 2026 was reviewed by this LPA. It was observed that entries for R1 had not been completed logging bowel movements for 04/23, NOC and PM shift, 04/25 AM shift, and 04/26 for NOC shift.

All other areas intended for resident use were toured. Furniture and furnishings were observed to be sufficient and able to meet the needs of the residents at this time.
It was learned that the facility has implemented Safely You monitoring in all memory care units.
LPA Pascua conducted a test of the facilities delayed egress system. A facility log book also was reviewed which documented the facilities daily check of the locked doors.
NAME OF LICENSING PROGRAM MANAGER: Lisa Rios
NAME OF LICENSING PROGRAM ANALYST: Arielle Pascua
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 04/27/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/27/2026
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: 04/27/2026
NARRATIVE
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The following documentation was requested to be submitted to this LPA by 05/01/2026 by 5:00pm
-Last medication audit conducted by the partnering pharmacy
-Staffing schedule for the March-April 2026.
-Medication Training past 3 months has been sent via email to arielle.pascua@dss.ca.gov for review
-Facility Polices Regarding: Assessments, Monitoring of Residents, Change in Condition, Medication Errors - any in services related to the above over the past 3 months to be sent via email to arielle.pascua@dss.ca.gov for review

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

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: Lisa Rios
NAME OF LICENSING PROGRAM ANALYST: Arielle Pascua
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 04/27/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/27/2026
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 04/27/2026 03:49 PM - It Cannot Be Edited


Created By: Arielle Pascua On 04/27/2026 at 03:00 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: 04/27/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
05/11/2026
Section Cited
HSC
1569.312(b)

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(b) Assistance with instrumental activities of daily living in the combinations which meet the needs of residents. This is not met as evidenced by: Based on record review, The licensee did not ensure that the facility staff completed and initialed the logs for assisgned tasks and duties and monthly assisgnments were completed.
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The facility shall conduct training regarding the following Section for no less than an hour in duration. A statement of correction indicating how often the facility will audit the assigned tasks and duties book
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This poses a potential health, safety, and personal rights risks to persons in care.
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and acknowledgement along with documented proof of scheduled training topics, dates, and times will be completed and submitted into CCL by the due date.

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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.
Lisa Rios
NAME OF LICENSING PROGRAM MANAGER:
Arielle Pascua
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 04/27/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/27/2026


LIC809 (FAS) - (06/04)
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