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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496803998
Report Date: 08/09/2024
Date Signed: 08/09/2024 02:31:00 PM


Document Has Been Signed on 08/09/2024 02:31 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
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405



FACILITY NAME:OAKMONT GARDENSFACILITY NUMBER:
496803998
ADMINISTRATOR:MORGAN HOLIENFACILITY TYPE:
740
ADDRESS:301 WHITE OAK DRIVETELEPHONE:
(707) 921-1861
CITY:SANTA ROSASTATE: CAZIP CODE:
95409
CAPACITY:79CENSUS: DATE:
08/09/2024
TYPE OF VISIT:Case Management - IncidentANNOUNCEDTIME BEGAN:
12:18 PM
MET WITH:Jody Livingston, Health and Wellness Director (HWD)TIME COMPLETED:
02:45 PM
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At approximately 12:15pm, Licensing Program Analyst (LPA) Christi Coppo arrived announced to conduct a case management visit in regards to an incident report submitted to CCL on 7/19/2024.

On 7/19/2024 the facility submitted to CCL an Incident report indicating a medication error had occurred at the facility. On 7/16/2024, facility began helping R1 with self-administration of medications. Incident report explains that at approximately 1:30am on 7/18/2024 resident (R1) reported to NOC shift caregiver (S1) needing their PRN pain medication. R1 has a physician's order for PRN Tramadol and scheduled Gabapentin. At this time, a Medication Technician (Med Tech) was not on schedule for the NOC shift, so S1 located the medication from the medication cart and provided it to R1. At approximately 6:00am, S1 reported to the oncoming day shift Med Tech (S2) that they had provided R1 with their PRN Tramadol and their scheduled Gabapentin.

S2 immediately report the incident to Health and Wellness Director (HWD). HWD then notified R1's responsible party and advised them of the incident. HWD also contacted Kaiser help line and left a message for R1's doctor. HWD left message for doctor and also sent over a fax indicating R1's medication error and inquiring as to a possible change in medication timing. Per R1's responsible party, the doctor was supposed to change the Gabapentin prescription from being scheduled every 4 hours to every 6 hours. HWD requested R1's responsible party to also follow up with doctor as HWD had not received a response back or call back from R1's doctor.

R1 did not exhibit any adverse reactions from the 1:30am dose of the PRN Tramadol and Gabapentin. Per R1's responsible party, the resident was believed to be self-administering the Gabapentin during these early morning hours prior to facility's start of helping R1 with their medication. LPA confirmed R1 still has not exhibited any adverse reactions stemming from medication error.

Continued on 809C...
SUPERVISOR'S NAME: Victoria BertozziTELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Christi CoppoTELEPHONE: (707) 588-5054
LICENSING EVALUATOR SIGNATURE:
DATE: 08/09/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/09/2024
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 3


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME: OAKMONT GARDENS
FACILITY NUMBER: 496803998
VISIT DATE: 08/09/2024
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Continued form 809...

Per LPA interview with HWD, S1 was terminated on 7/19/2024. Facility did not place R1 on 72 hour monitoring because the medications given were within the parameters of the physician's orders. Facility change their scheduling of Med Techs in response to this incident. Facility now has a Med Tech assigned to each shift, including NOC shift. If for any reason a Med Tech is not available to work their shift, then HWD is committed to covering the needed shift in order to ensure that someone is attending to medications 24 hours per day.

Facility conducted training with staff caregivers and had them sign a form indicating that they are not to administer medication for any resident, at any time, for any reason. In addition to the training conducted with caregivers, facility also conducted training with staff Med Techs and had them sign a form indicating that they are aware of the medication policy and procedures. As an extra precaution, HWD is currently in the process of redesigning medication room for improved safety and to mitigate medication errors. HWD provided training logs and acknowledgements to LPA during case management. Additionally, HWD conduct audit of medication counts to verify all medications administered match current medication counts.
SUPERVISOR'S NAME: Victoria BertozziTELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Christi CoppoTELEPHONE: (707) 588-5054
LICENSING EVALUATOR SIGNATURE:

DATE: 08/09/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/09/2024
LIC809 (FAS) - (06/04)
Page: 2 of 3
Document Has Been Signed on 08/09/2024 02:31 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
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405


FACILITY NAME: OAKMONT GARDENS
FACILITY NUMBER: 496803998

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/09/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
08/19/2024
Section Cited
CCR
87465(a)(4)

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Incidental Medical and Dental Care 87465(a)(4) The licensee shall assist residents with self-administered medications as needed.

This requirement not met by licensee as evidenced by:
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Facility terminated S1. Facility conducted staff training. Deficiency cleared.
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Based on facility's submitted incident report reporting medication error, 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: Victoria BertozziTELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Christi CoppoTELEPHONE: (707) 588-5054
LICENSING EVALUATOR SIGNATURE:
DATE: 08/09/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/09/2024
LIC809 (FAS) - (06/04)
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