392701272-1-17-2024-27-AS-KHOS-CZRQY7-20240123113441

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 392701272
Report Date: 01/17/2024
Date Signed: 01/17/2024 01:45:45 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
11/07/2023 and conducted by Evaluator Avelina Martinez

PUBLIC

COMPLAINT CONTROL NUMBER: 27-AS-20231107162650

FACILITY NAME:	OAKMONT OF LODI		FACILITY NUMBER:	392701272
ADMINISTRATOR:	SMITH, EUGENIA		FACILITY TYPE:	740
ADDRESS:	2905 REYNOLDS RANCH PARKWAY		TELEPHONE:	(209) 310-1512
CITY:	LODI	STATE: CA	ZIP CODE:	95240
CAPACITY:	136	CENSUS: 85	DATE:	01/17/2024
		UNANNOUNCED	TIME BEGAN:	09:15 AM
MET WITH:	Andrea Armstrong		TIME COMPLETED:	02:15 PM

ALLEGATION(S):

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Facility failed to provide care and supervision.
Facility failed to seek timely medical care.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Avelina Martinez arrived at the facility unannounced on 01/17/2024 at 9:15 AM to deliver complaint findings, LPA Martinez met with Administrator, Andrea Armstrong, and explained the purpose of the visit.

Throughout the course of the investigation, LPA Martinez conducted interviews, shadowed staff, toured the facility, and conducted file reviews. It was learned resident 1 (R1) slid off their bed onto the floor, and did not have their call button pendent at time due to R1 taking off their call button pendent. The time of incident was undetermined due to R1 not being checked on. The time frame of the incident is sometime between October 26, 2023 around 8:00 PM and October 27, 2023 at approximately 4:00 PM. Furthermore, it is unknown how long R1 was on the floor due to not being checked on. R1 was found by staff in their room on the floor naked on October 27, 2023. R1 sustained rug burns, skin tears, and bruising. R1 was sent to the Emergency Room (ER) and was later transferred to a skilled nursing facility (SNF).

Continued...

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Liza King	TELEPHONE: (650) 676-0442
LICENSING EVALUATOR NAME: Avelina Martinez	TELEPHONE: (916) 431-8935
LICENSING EVALUATOR SIGNATURE:	DATE: 01/17/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/17/2024

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 4

Control Number 27-AS-20231107162650

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: 01/17/2024

NARRATIVE

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As a result, the facility was not monitoring/ensuring R1's general health, safety, and well-being needs were being met. Moreover, the investigation revealed the facility was short staff during the AM shift (6:00 AM to 2:30 PM). During the AM shift, there was one med-tech and one care staff assigned to the Assisted Living unit. Throughout the investigation, LPA Martinez was informed AM staff did not check on R1. Additionally, R1 missed breakfast and lunch, and facility staff did not check on R1 after the missing meals.

Facility staff conducted a safety check after the facility concierge received a phone call from R1's responsible party (RP). Care staff provided first aid care, assisted R1 off the ground, and helped dress R1. Facility staff called 911 after resident was found on the floor for an undetermined amount of hours. Due to the fact that the facility did not provide basic services to R1, the facility did not provided timely medical attention. As a result of this investigation, the Department finds these allegations to be Substantiated. A finding that the complaint is substantiated means that the allegations are valid because the preponderance of the evidence standard has been met. Deficiencies cited on the LIC 9099-D page, per Title 22 Regulations.

Due to R1 sustaining serious bodily injury, the violation warrants civil penalty assessments. At this time, the civil penalty assessments are under review, and a civil penalty determination is pending by the Department. Once civil penalty assessments have been determined, an LPA will return at a future date to assess the civil penalties. An immediate $500.00 civil penalty shall be assessed on January 17, 2024; based on the fact the facility failed to provide basic care services to R1, which posed an immediate threat to the Health, Safety, and Personal Rights of R1. Please refer to 9099-D page for civil penalty: 1569.312(e) Basic services requirements.

An exit interview was conducted, and a copy of this 9099 report, LIC 9099-D, and appeal rights were provided to the facility. Failure to correct any deficiencies by plan of correction due dates may result in civil penalties.

SUPERVISOR'S NAME: Liza King	TELEPHONE: (650) 676-0442
LICENSING EVALUATOR NAME: Avelina Martinez	TELEPHONE: (916) 431-8935
LICENSING EVALUATOR SIGNATURE:	DATE: 01/17/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/17/2024

LIC9099 (FAS) - (06/04)

Page: 3 of 4

Control Number 27-AS-20231107162650

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: 01/17/2024

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 01/17/2024 Section Cited HSC 1569.312(e)	1 2 3 4 5 6 7	1569.312(e) Basic services requirements: Every facility required to be licensed under this chapter shall provide at least the following basic services: Monitoring the activities of the residents while they are under the supervision of the facility to ensure their general health, safety, and well-being.	1 2 3 4 5 6 7	The Administrator reported basic services training was conducted on 01/05/2023. POC was cleared at time of visit.
	8 9 10 11 12 13 14	This requirement was not met as evidence by: Based on file review and interviews, the Licensee did not ensure R1 was monitored daily. R1 was found on the ground unable to get up from the floor for hours due to lack of monitoring/basic services. This posed an immediate health and safety risk to R1.	8 9 10 11 12 13 14
Request Denied Type A 01/17/2024 Section Cited CCR 87465(g)	1 2 3 4 5 6 7	87465(g) Incidental Medical and Dental Care The licensee shall immediately telephone 9-1-1 if an injury or other circumstance has resulted in an imminent threat to a resident’s health...This requirement was not met as evidence by. Based on file review and interviews,	1 2 3 4 5 6 7	The Administrator reported Incidental and medical training was conducted on 01/05/2023. POC was cleared at time of visit.
	8 9 10 11 12 13 14	The Licensee did not ensure to seek timely medical attention for R1. R1 was not monitored/check on 10/27/23 and when R1 was checked on R1 was found naked on the ground, and R1 was on the ground for an undetermined amount of hours. This posed an immediate health and safety risk to R1.	8 9 10 11 12 13 14

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	TELEPHONE: (650) 676-0442
LICENSING EVALUATOR NAME: Avelina Martinez	TELEPHONE: (916) 431-8935
LICENSING EVALUATOR SIGNATURE:	DATE: 01/17/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/17/2024

LIC9099 (FAS) - (06/04)

Page: 2 of 4

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
11/07/2023 and conducted by Evaluator Avelina Martinez

PUBLIC

COMPLAINT CONTROL NUMBER: 27-AS-20231107162650

FACILITY NAME:	OAKMONT OF LODI		FACILITY NUMBER:	392701272
ADMINISTRATOR:	SMITH, EUGENIA		FACILITY TYPE:	740
ADDRESS:	2905 REYNOLDS RANCH PARKWAY		TELEPHONE:	(209) 310-1512
CITY:	LODI	STATE: CA	ZIP CODE:	95240
CAPACITY:	136	CENSUS: 88	DATE:	01/17/2024
		UNANNOUNCED	TIME BEGAN:	09:15 AM
MET WITH:	Andrea Armstrong		TIME COMPLETED:	02:15 PM

ALLEGATION(S):

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Facility failed to provide care as identified on the care plan.

INVESTIGATION FINDINGS:

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On 01/17/2024 at 9:15 AM, Licensing Program Analyst (LPA) Avelina Martinez arrived at the facility unannounced to deliver complaint findings. LPA met with Andrea Armstrong during today’s visit, and LPA Martinez explained the purpose of today's visit.

Throughout the course of this investigation, LPA Martinez conducted interviews and reviewed facility files. LPA Martinez reviewed Resident 1 (R1) Assessment form dated July, 03, 2023. It was learned R1 did not require a lot of care. R1 was assessed two points for care and base rate rent. R1 was mostly independent with activities of daily living (ADL's). It was determined there was not sufficient evidence to prove the facility was not providing care identified on R1's care plan. Due to the above noted information, although the allegation may have happened or is 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 King	TELEPHONE: (650) 676-0442
LICENSING EVALUATOR NAME: Avelina Martinez	TELEPHONE: (916) 431-8935
LICENSING EVALUATOR SIGNATURE:	DATE: 01/17/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/17/2024

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

Page: 4 of 4