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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 496803998
Report Date: 12/19/2023
Date Signed: 12/19/2023 02:01:03 PM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
This is an official report of an unannounced visit/investigation of a complaint received in our office on
11/13/2023 and conducted by Evaluator David Leibert
COMPLAINT CONTROL NUMBER: 21-AS-20231113084830
FACILITY NAME:OAKMONT GARDENSFACILITY NUMBER:
496803998
ADMINISTRATOR:SORIANO, MARIELEFACILITY TYPE:
740
ADDRESS:301 WHITE OAK DRIVETELEPHONE:
(707) 921-1861
CITY:SANTA ROSASTATE: ZIP CODE:
95409
CAPACITY:79CENSUS: 46DATE:
12/19/2023
UNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Morgan HolienTIME COMPLETED:
02:00 PM
ALLEGATION(S):
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Staff mismanaged residents medication
Staff did not seek medical attention in a timely manner
INVESTIGATION FINDINGS:
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Licensing Program Analyst Leibert arrives unannounced for the purpose of delivering findings on this complaint. Complainant alleges that staff made errors regarding resident's (R1) medications and that R1 was not provided timely medical attention following a fall on 10/31/2023. Through investigative interviews and review of pertinent documents, the following determinations are made: The specific medications and dates of alleged errors were not reported to CCL; Health Services Director states that any medications not given were due to R1's absence from the facility; Facility reports that R1 initially indicated a lack of pain and declined medical treatment following R1's fall; Staff reportedly checked R1 daily for changes in gait and pain; R1 was sent out for medical treatment on day three when R1 reported pain and requested treatment; Facility's Report of Injury (LIC624) conforms with staff statements regarding the accident. Although allegations may be true, based upon the statements made and documents reviewed, there is not a preponderance of evidence to prove the allegations are true or, not true. Therefore, the allegations are UNSUBSTANTIATED.
Report left.
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Carla MartinezTELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: David LeibertTELEPHONE: (707) 588-5086
LICENSING EVALUATOR SIGNATURE:

DATE: 12/19/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/19/2023
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 3
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
This is an official report of an unannounced visit/investigation of a complaint received in our office on
11/13/2023 and conducted by Evaluator David Leibert
COMPLAINT CONTROL NUMBER: 21-AS-20231113084830

FACILITY NAME:OAKMONT GARDENSFACILITY NUMBER:
496803998
ADMINISTRATOR:SORIANO, MARIELEFACILITY TYPE:
740
ADDRESS:301 WHITE OAK DRIVETELEPHONE:
(707) 921-1861
CITY:SANTA ROSASTATE: ZIP CODE:
95409
CAPACITY:79CENSUS: 46DATE:
12/19/2023
UNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Morgan HolienTIME COMPLETED:
02:00 PM
ALLEGATION(S):
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9
Staff do not respond to call bells in a timely manner.
Reporting requirements not met
INVESTIGATION FINDINGS:
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Licensing Program Analyst Leibert arrives unannounced for the purpose of delivering findings. It is alleged that staff do not respond to call bells timely and that facility did not comply with requirement to notify responsible person of R1’s injury and medication errors. Through investigative interviews and review of pertinent documents, the following determinations are made: Call logs for R1’s room in October 2023 show that out of 22 responses to call bells, six responses were over 25 minutes and one response was for 126 minutes; Following the incident of 10/31 when R1 fell and sustained injury R1’s Responsible Person was contacted by phone that evening but states no written report was received as required by regulation; The written Incident Report does not indicate a copy was provided to the Responsible Person; This investigation did not determine medication errors occurred. Based on the statements made and documents reviewed, the preponderance of evidence standard has been met. Therefore, the allegations are SUBSTANTIATED. The following deficiencies were observed (see LIC 9099D) and cited from the California Code of Regulations, Title 22, Division 6 of California Regulation. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties. Exit interview conducted at 2:00pm and appeal of rights provided.
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Carla MartinezTELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: David LeibertTELEPHONE: (707) 588-5086
LICENSING EVALUATOR SIGNATURE:

DATE: 12/19/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/19/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 21-AS-20231113084830
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: OAKMONT GARDENS
FACILITY NUMBER: 496803998
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/19/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
12/19/2023
Section Cited
CCR
87411(a)
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Personnel Requirements. Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs. ***This requirement has not been met as evidenced by: Based upon review of call log records, out of 22 responses
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Cleared at time of visit. Administration has submitted a written plan addressing timely responses to call buttons on 12/13/2023 for a more recent complaint regarding the same issue.
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for calls to R1’s room in October, 2023, six exceeded 25 minutes and one was 126 minutes. This posed an immediate risk to the health and safety of residents in care.
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Type B
01/02/2024
Section Cited
CCR
87211(a)(1)
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Reporting Requirements…. A written report shall be submitted.. to the person responsible for the resident within seven days of the occurrence of any of the events specified in (A) through (D…***Based upon statements made and documents reviewed, this requirement has not been
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Administration will review the requirements of 87211 and provide refresher training to staff responsible for Incident Reports. Proof of refresher training will clear the deficiency when submited to CCL by the POC date.
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met as evidenced by: R1’s Responsible Person states RP did not receive a copy of the Incident Report for 10/31 and the Report does not indicate a copy was provided to the Responsible Person. This posed a potential risk to the personal rights of R1.
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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: Carla MartinezTELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: David LeibertTELEPHONE: (707) 588-5086
LICENSING EVALUATOR SIGNATURE:

DATE: 12/19/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/19/2023
LIC9099 (FAS) - (06/04)
Page: 3 of 3