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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202772
Report Date: 07/21/2023
Date Signed: 07/21/2023 09:37:38 PM


COMPREHENSIVE INSPECTION

Document Has Been Signed on 07/21/2023 09:37 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
CENTRAL COAST CR/RES, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131



FACILITY NAME:OAKMONT OF SILVER CREEKFACILITY NUMBER:
435202772
ADMINISTRATOR:BAGHERI, TAYEBEHFACILITY TYPE:
740
ADDRESS:3544 SAN FELIPE ROADTELEPHONE:
(669) 288-5000
CITY:SAN JOSESTATE: CAZIP CODE:
95135
CAPACITY:148CENSUS: 62DATE:
07/21/2023
TYPE OF VISIT:Case Management - Annual ContinuationUNANNOUNCEDTIME BEGAN:
03:00 PM
MET WITH:Executive Director, James DialTIME COMPLETED:
09:45 PM
NARRATIVE
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Licensing Program Analyst (LPA) Simi Rai arrived unannounced to conduct a continuation of the annual inspection from 7/3/2023 and met with Executive Director (ED), James Dial.

During visit, LPA Rai review randomly 3 resident files and 3 staff files. Facility will make sure the resident files are complete, including signed copies of LIC 613C Resident's Rights. Facility will make sure the staff files are complete, including signed LIC 9052 Employee Rights and LIC 508 Criminal Record Statement. Based on record review, S3's employee file did not contain TB test results but the LIC 502 Health Screening was complete. LPA Rai interviewed S3 and S3 stated TB test results were negative and will obtain a copy and give to ED.

During a random review/audit of Assisted Living resident's medication bottle and LIC 622 Centrally Stored Medication and Destruction Record, 5 out of 9 medications prescribed to R1 was not given as prescribed by the doctor. LPA Rai along with Staff (S4) counted the tablets from the medication bottles.
R1's medication #1 were counted 73 tablets instead of 69/100 tablets, 4 medications were not administered. Based on review of R1's electronic MARs, S4 stated that R1's medications were administered daily from 6/20/2023 to 7/20/2023 with an exemption of 7/15/2023 wherein R1 refused to take 1 tablet.
R1's medication #2 were counted 86 tablets instead of the medication bottle should be empty if given as prescribed. Based on review of R1's electronic MARs, Staff (S4) stated that R1's medications were administered daily from 4/3/2023 to 7/21/2023. S4 stated R1's physician did place the medication on hold but could not find physician's order to hold medication. Based on review of R1's electronic MARs there was no note stated medication was on hold.

Continuation on LIC 809-C.
Page 1 of 3.
SUPERVISOR'S NAME: Romeo ManzanoTELEPHONE: (650) 388-2297
LICENSING EVALUATOR NAME: Simranjit RaiTELEPHONE: (408) 324-2112
LICENSING EVALUATOR SIGNATURE:
DATE: 07/21/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/21/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 4


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CENTRAL COAST CR/RES, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131
FACILITY NAME: OAKMONT OF SILVER CREEK
FACILITY NUMBER: 435202772
VISIT DATE: 07/21/2023
NARRATIVE
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R1's medication #3 were counted 123 tablets instead of 119/200 tablets, 4 medications were not administered. Based on review of R1's electronic MARs, S4 stated that R1's medications were administered 1 tablet twice a day from 6/11/2023 to 7/21/2023 with an exemption of 7/15/2023 wherein R1 refused to take 1 tablet.
R1's medication #4 were counted 53 tablets instead of 22/400 tablets, 31 medications were not administered. Based on review of R1's electronic MARs, S4 stated R1' medications were administered 1 tablet twice a day from 1/14/2023 to 7/21/2023 with an exemption of 7/15/2023 wherein R1 refused to take 1 tablet.

During a random review/audit of Memory Care resident's medication bottle and LIC 622 Centrally Stored Medication and Destruction Record, 1 out of 5 medications prescribed to R2 was not given as prescribed by the doctor. LPA Rai along with Staff (S4) counted the tablets from the medication bottles.
R2's medication #1 were counted 23 tablets instead of 16/100 tablets, 7 medications were not administered. Based on review R2's electronic MARS, S4 stated that R2's medication were administered daily from 4/29/2023 to 7/21/2023 with an exemption of 6/18/2023 wherein R2 was out of the facility.

During interview with Staff 4, S4 stated there were days when R1 refused to take his/her medication but S4 noted on electronic MARs the medication was administered to R1. S4 stated he/she is unaware of why he/she would state on electronic MARs the medication was given when he/she remembers not administering
the medication to R1. S4 did review electronic MARs with LPA Rai and S4 pointed out 4 days S4 remembers R1 refusing medication: July 14, July 15, July 18 and July 19. Based on review of electronic MARS, LPA Rai observed one note on July 15 stated R1 refused to take medications, but the other 3 days record S4 giving medication to R1. S4 stated electronic MARs for R1 does not reflect R1's refusal of medication, which is false record of R1's electronic MARs.

Continuation on LIC 809-C.
SUPERVISOR'S NAME: Romeo ManzanoTELEPHONE: (650) 388-2297
LICENSING EVALUATOR NAME: Simranjit RaiTELEPHONE: (408) 324-2112
LICENSING EVALUATOR SIGNATURE:

DATE: 07/21/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/21/2023
LIC809 (FAS) - (06/04)
Page: 4 of 4
Document Has Been Signed on 07/21/2023 09:37 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CENTRAL COAST CR/RES, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131


FACILITY NAME: OAKMONT OF SILVER CREEK
FACILITY NUMBER: 435202772

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/21/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
07/22/2023
Section Cited
CCR
87411(a)

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87411 Personnel Requirements - General
(a) Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs.
This requirement is not met as evidenced by:
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Executive Director submit a written plan on understanding regulations and schedule in-services and training to staff by POC date.
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Based on record review, interview and observation R1's 5 out of 9 meds not administered to R1 as prescribed by the MD and R2's 1 out of 5 meds were not administered to R2 as prescribed by the MD which poses an immediate Health, Safety, or Personal Rights risk to persons in care.
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Type A
07/22/2023
Section Cited
CCR87207

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87207 False Claims No licensee, officer or employee of a licensee shall make or disseminate any false or misleading statement regarding the facility or any of the services provided by the facility.

This requirement is not met as evidenced by:
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Executive Director submit a written plan on understanding regulations and schedule in-services and training to staff by POC date.
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Based on record review, interview and observation, R1-R2 electronic MARs noted medications administered but S4 and S5 stated R1 refused medication and R2 was out of the facility, which poses an immediate Health, Safety, or Personal Rights risk to persons in care.
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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: Romeo ManzanoTELEPHONE: (650) 388-2297
LICENSING EVALUATOR NAME: Simranjit RaiTELEPHONE: (408) 324-2112
LICENSING EVALUATOR SIGNATURE:
DATE: 07/21/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/21/2023
LIC809 (FAS) - (06/04)
Page: 2 of 4


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CENTRAL COAST CR/RES, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131
FACILITY NAME: OAKMONT OF SILVER CREEK
FACILITY NUMBER: 435202772
VISIT DATE: 07/21/2023
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Page 3 of 3.
During interview with Staff 5, S5 stated there were days when R2 was not in the facility. S5 stated R2 went out of the facility 5/8/2023 and came back 5/9/2023 evening and medication #1 is prescribed by MD to be administered in the morning and electronic MARs should reflect the missed dose. Based on review of R2's electronic MARs, 5/9/2023 stated medications was given to R2, which is false record of R2's electronic MARs.

Deficiencies were cited from California Code of Regulations, Title 22 during today’s visit, see LIC 809-D.
87411 Personnel Requirements - General is being cited during today's visit. LPA Rai would like to clarify the facility personnel being in sufficient in numbers is not the concern, however the facility personnel's actions and documentation are observed to be not competent to provide the services necessary to meet the resident's needs.

Exit interview was conducted with Executive Director, James Dial. A copy of this report was provided to Executive Director, James Dial. Appeal Rights were provided.
SUPERVISOR'S NAME: Romeo ManzanoTELEPHONE: (650) 388-2297
LICENSING EVALUATOR NAME: Simranjit RaiTELEPHONE: (408) 324-2112
LICENSING EVALUATOR SIGNATURE:

DATE: 07/21/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/21/2023
LIC809 (FAS) - (06/04)
Page: 3 of 4