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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 392701272
Report Date: 03/21/2024
Date Signed: 03/21/2024 03:24:39 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
This is an official report of an unannounced visit/investigation of a complaint received in our office on
12/15/2023 and conducted by Evaluator Avelina Martinez
PUBLIC
COMPLAINT CONTROL NUMBER: 27-AS-20231215103201
FACILITY NAME:OAKMONT OF LODIFACILITY NUMBER:
392701272
ADMINISTRATOR:ARMSTRONG, ANDREAFACILITY TYPE:
740
ADDRESS:2905 REYNOLDS RANCH PARKWAYTELEPHONE:
(209) 310-1512
CITY:LODISTATE: CAZIP CODE:
95240
CAPACITY:136CENSUS: 86DATE:
03/21/2024
UNANNOUNCEDTIME BEGAN:
12:45 PM
MET WITH:Andrea Armstrong TIME COMPLETED:
03:45 PM
ALLEGATION(S):
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Resident was not being given medications as needed.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Avelina Martinez arrived at the facility unannounced on 03/21/2024 at 12:45 PM to deliver complaint findings, LPA Martinez met with Andrea Armstrong and explained the purpose of the visit.

Throughout the course of the investigation, LPA Martinez conducted interviews and reviewed facility documents. It was learned resident 1 (R1) was sent to the Emergency Room (ER) on October 27, 2023. R1 returned to Oakmont of Lodi facility on November 15, 2023. Upon return, R1 required a higher level of care. R1 was reassessed and their Individualized Service Plan (ISP) was updated. R1 required Medication Management Services. The ISP states the following: " Requires medication assistance with 1 to 5 medications including all oral, topical, inhalers, drops, patches, supplements and PRN medications... medication storage included... expected result: receives medication in a timely manner...task description: assist with medication administration as order." In addition, R1 was assessed 30 acuity points for medication management and 30 billable points. Continued...
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Liza KingTELEPHONE: (650) 676-0442
LICENSING EVALUATOR NAME: Avelina MartinezTELEPHONE: (916) 431-8935
LICENSING EVALUATOR SIGNATURE:

DATE: 03/21/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/21/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 7
Control Number 27-AS-20231215103201
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 03/21/2024
NARRATIVE
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LPA Martinez requested a copy of R1's medication administration record (MAR). LPA Martinez was informed by the facility Administrator that the facility does not have MARs for R1 on February 28, 2024. It was learned the facility did not administer medication to R1.

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 3/21/2024. Please refer to LIC 421IM form for additional information.

As a result of this investigation, the Department finds this allegation to be Substantiated. A finding that the complaint is substantiated means that the allegation is valid because the preponderance of the evidence standard has been met. Deficiency cited on the LIC 9099-D, per Title 22 Regulations.



An exit interview was conducted, and a copy of this report was provided to the facility.
SUPERVISOR'S NAME: Liza KingTELEPHONE: (650) 676-0442
LICENSING EVALUATOR NAME: Avelina MartinezTELEPHONE: (916) 431-8935
LICENSING EVALUATOR SIGNATURE:

DATE: 03/21/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/21/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 7
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
This is an official report of an unannounced visit/investigation of a complaint received in our office on
12/15/2023 and conducted by Evaluator Avelina Martinez
PUBLIC
COMPLAINT CONTROL NUMBER: 27-AS-20231215103201

FACILITY NAME:OAKMONT OF LODIFACILITY NUMBER:
392701272
ADMINISTRATOR:ARMSTRONG, ANDREAFACILITY TYPE:
740
ADDRESS:2905 REYNOLDS RANCH PARKWAYTELEPHONE:
(209) 310-1512
CITY:LODISTATE: CAZIP CODE:
95240
CAPACITY:136CENSUS: 86DATE:
03/21/2024
UNANNOUNCEDTIME BEGAN:
12:45 PM
MET WITH:Andrea ArmstrongTIME COMPLETED:
03:45 PM
ALLEGATION(S):
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Facility failed to provide care and supervision to resident.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Avelina Martinez arrived at the facility unannounced on 03/21/2024 at 12:45 PM to deliver complaint findings, LPA Martinez met with Andrea Armstrong and explained the purpose of the visit.

Moreover, LPA Martinez interviewed 5 out of 5 staff who provided care and supervision to R1. 5 out of 5 staff reported they have did not witness R1 being left in the restroom unattended. The five staff also reported they had no knowledge of R1 being left in the bathroom unattended. Facility documents did not document any incidents regarding R1 being left in the restroom unattended. Due to the above noted information, although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, and therefore the allegation is unsubstantiated.
An exit interview was conducted, and a copy of this report was provided to the facility.

Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Liza KingTELEPHONE: (650) 676-0442
LICENSING EVALUATOR NAME: Avelina MartinezTELEPHONE: (916) 431-8935
LICENSING EVALUATOR SIGNATURE:

DATE: 03/21/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/21/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 3 of 7
Control Number 27-AS-20231215103201
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/21/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
03/22/2024
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 is actively recruiting a Well Nurse to assist with Medication Compliance. Medication Training was recently provided in February, next training is next month. Medication audits are done every Thursday. A medication audit is scheduled for later today.
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Based on file review and interviews, the Licensee did not ensure staff were administering medications to R1. This posed and immediate health and safety risk to R1.
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Facility staff agrees to email LPA Martinez Training Agenda and Wellness nurse recruiting plan by 03/22/24 by 5:00 PM.
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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 KingTELEPHONE: (650) 676-0442
LICENSING EVALUATOR NAME: Avelina MartinezTELEPHONE: (916) 431-8935
LICENSING EVALUATOR SIGNATURE:

DATE: 03/21/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/21/2024
LIC9099 (FAS) - (06/04)
Page: 5 of 7
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
This is an official report of an unannounced visit/investigation of a complaint received in our office on
12/15/2023 and conducted by Evaluator Avelina Martinez
PUBLIC
COMPLAINT CONTROL NUMBER: 27-AS-20231215103201

FACILITY NAME:OAKMONT OF LODIFACILITY NUMBER:
392701272
ADMINISTRATOR:ARMSTRONG, ANDREAFACILITY TYPE:
740
ADDRESS:2905 REYNOLDS RANCH PARKWAYTELEPHONE:
(209) 310-1512
CITY:LODISTATE: CAZIP CODE:
95240
CAPACITY:136CENSUS: 86DATE:
03/21/2024
UNANNOUNCEDTIME BEGAN:
12:45 PM
MET WITH:Andrea Armstrong TIME COMPLETED:
03:45 PM
ALLEGATION(S):
1
2
3
4
5
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9
Facility did not adhere to resident's signed admission agreement.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Avelina Martinez arrived at the facility unannounced on 03/21/2024 at 12:45 PM to deliver complaint findings, LPA Martinez met with Andrea Armstrong and explained the purpose of the visit.

Throughout the course of the investigation, LPA Martinez conducted interviews and reviewed facility documents. LPA Martinez reviewed resident 1's (R1) signed admission agreement. Section E...Page 7 states, "If you move out without providing a thrity (30) day notice, you will be responsbile for the amount of you monthly fee through the day you move plus one full's month rent." Facility documentation states move out notice was provided to the facility on November 27, 2023. R1's move out date was November 29, 2023. According to the documents, a 30-day move out notice was not provided to the facility 30 days prior to moving out.

Continued...
Unfounded
Estimated Days of Completion:
SUPERVISOR'S NAME: Liza KingTELEPHONE: (650) 676-0442
LICENSING EVALUATOR NAME: Avelina MartinezTELEPHONE: (916) 431-8935
LICENSING EVALUATOR SIGNATURE:

DATE: 03/21/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/21/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 6 of 7
Control Number 27-AS-20231215103201
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 03/21/2024
NARRATIVE
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Additionally, R1 was refunded a total of $2,292.92 on December 19, 2023 to cover rent and care and supervision.

This agency has investigated the complaint alleging (Facility did not adhere to resident's signed admission agreement). We have found that the complaint was unfounded, meaning that the allegation was false, could not have happened and/or is without a reasonable basis.

An exit interview was conducted, and a copy of this report was provided to the facility.

SUPERVISOR'S NAME: Liza KingTELEPHONE: (650) 676-0442
LICENSING EVALUATOR NAME: Avelina MartinezTELEPHONE: (916) 431-8935
LICENSING EVALUATOR SIGNATURE:

DATE: 03/21/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/21/2024
LIC9099 (FAS) - (06/04)
Page: 7 of 7