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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 392701272
Report Date: 10/17/2024
Date Signed: 10/18/2024 08:24:35 AM

Document Has Been Signed on 10/18/2024 08:24 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 LODIFACILITY NUMBER:
392701272
ADMINISTRATOR/
DIRECTOR:		ARMSTRONG, ANDREAFACILITY TYPE:
740
ADDRESS:2905 REYNOLDS RANCH PARKWAYTELEPHONE:
(209) 310-1512
CITY:LODISTATE: CAZIP CODE:
95240
CAPACITY: 136CENSUS: 96DATE:
10/17/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:00 PM
MET WITH:Asha PrasadTIME VISIT/
INSPECTION COMPLETED:
04:00 PM
NARRATIVE
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Unannounced annual visit made out to this facility on 10/17/2024 by Licensing Program Analyst (LPA) Charlie Yang who was met by the facility designated representative, Asha Prasad, who was briefly interviewed. This LPA requested that she go ahead and contact the facility designated Administrator, Andrea Armstrong, to inform her that CCL was present at this time. It was learned that Mrs. Armstrong was unable to be present during today's annual visit. This annual visit was conducted with the facility Business Office Director, Asha Prasad, at this time.
Current census was 96 residents.
It was learned that there were (6) residents under the care of hospice at this time while (10) other residents were receiving services through home health as well.
This facility does have a hospice waiver approved for (15) residents and fire cleared for bedridden and dementia care for residents at any given time.
A tour of this facility was conducted.
Administrator certificate was observed to be present for facility designated Administrator Andrea Armstrong at this time.
Kitchen area was toured. Cabinets and drawers were reviewed. Food preparation stations, dishwashing station, and other areas intended for meal preps were toured.
Food supply was reviewed for adequate 2-day perishable and 7-day nonperishable quantities at this time. This LPA did observe additional food storage units which were present and functional at this time.
A tour of the dining area, living area, and all other areas intended for resident use was conducted.
Medication rooms, located on each floor, were reviewed. Policies and procedures involving dispensing, documenting, and overall administration of resident medications were discussed with the facility designated medication technicians at this time. The medication carts were observed to be locked and made inaccessible to the residents at this time.
A tour of the resident bedrooms and restroom was conducted. Furniture and furnishings were observed to be sufficient and able to meet the needs of the residents at this time. It was learned that there were several
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Charlie Yang
LICENSING EVALUATOR SIGNATURE: DATE: 10/17/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/17/2024
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: 10/17/2024
NARRATIVE
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different floor plans for residents on the Assisted Living portion of this facility.
Hot water temperatures were taken and measured to make sure that they were within the allowed range of 105-120 degrees.
Linen closet, located in the facility laundry area, was observed to contain a sufficient supply of towels, blankets, and linens to meet the needs of the residents at this time.
A tour of the Memory Care portion was conducted.
Fire extinguishers, located throughout this facility, were observed to have been annually inspected on 04/18/2024 by the local fire extinguisher company, Alpha Fire Control, and in compliance at this time.
First aid kits were observed to be present and contained all of the required components at this time.
Exterior grounds of this facility were toured.
A review of the facility perimeter fence, side gates, and exits was conducted.

A review of (10) facility resident files was conducted.
A review of (10) facility personnel files was conducted.

The following forms and documents were requested to be updated and submitted into CCL:
  • LIC 308

  • LIC 400

  • LIC 500

  • LIC 610


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

Appeal Rights were printed and a copy was given to the facility representative, Asha Prasad, at this time.

Exit Interview
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Charlie Yang
LICENSING EVALUATOR SIGNATURE:

DATE: 10/17/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/17/2024
LIC809 (FAS) - (06/04)
Page: 2 of 4
Document Has Been Signed on 10/18/2024 08:24 AM - It Cannot Be Edited


Created By: Charlie Yang On 10/17/2024 at 05:13 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: 10/17/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Deficiency Dismissed
Type A
Section Cited
HSC
1569.618(c)(3)
Other Provisions
(c)The facility shall employ, and the administrator shall schedule, a sufficient number of staff members to do all of the following: (3) Ensure that at least one staff member who has cardiopulmonary resuscitation (CPR) training and first aid training is on duty and on the premises at all times. This paragraph shall not be construed to require staff to provide CPR.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in that [3] out of [10] facility personnel files did not have updated First Aid Training which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 10/18/2024
Plan of Correction
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The facility representative stated that all facility staff providing care and supervision to the residents will be scheduled for First Aid Training. A statement of correction, along with copies of updated First Aid Training certificates, will be completed and submitted into CCL by the due date.
Deficiency Dismissed
Type A
Section Cited
CCR
87465(c)(2)
Incidental Medical and Dental Care Services
(c) If the resident's physician has stated in writing that the resident is unable to determine his/her own need for nonprescription PRN medication, but can communicate his/her symptoms clearly, facility staff designated by the licensee shall be permitted to assist the resident with self-administration, provided all of the following requirements are met: (2) Once ordered by the physician the medication is given according to the physician's directions.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and record review, the licensee did not comply with the section cited above in that the narcotic counts were incomplete missing required information. In addition, there were errors in documentation for days when the narcotics were dispensed to the residents which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 10/24/2024
Plan of Correction
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The facility representative stated that all facility staff dispensing, handling, and documenting the resident medications will be in-serviced, for no less that (2) hours in duration, on the topics of proper dispensing, handling, and documentation of the resident medications. A statement of correction, along with proof of updated staff training, will be completed and submitted into CCL by the due date.
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: 10/17/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/17/2024


LIC809 (FAS) - (06/04)
Page: 3 of 4
Document Has Been Signed on 10/18/2024 08:24 AM - It Cannot Be Edited


Created By: Charlie Yang On 10/17/2024 at 05:13 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: 10/17/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87506(b)
Resident Records
(b) Each resident's record shall contain at least the following information:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in that [10] out of [10] facility resident files were missing required forms and documents which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/24/2024
Plan of Correction
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The facility representative stated that all facility resident files will be audited and any, and all, missing forms and documents will be updated and brought into compliance. A statement of correction, along with copies of all updated forms and documents, will be completed and submitted into CCL by the due date.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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:Charlie Yang
LICENSING EVALUATOR SIGNATURE:
DATE: 10/17/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/17/2024


LIC809 (FAS) - (06/04)
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