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Inspection visit

Incident investigation

OAKMONT OF EAST SACRAMENTOLicense 3427011212 citations on this visit
2 citations recorded

Inspector’s narrative

What the inspector wrote

On 07/23/2024, Licensing Program Analysts (LPAs) Arielle Pascua and Pang Lee arrived unannounced to conduct a case management visit. LPAs met with Facility Designated Administrator (FDA), Kathleen Gilbey and explained the purpose of the visit. The purpose of this visit was to follow up on an incident report received by the department on 06/29/2024. On 06/23/2024, the department received an LIC 624 incident report that occurred on 06/23/2024 regarding resident 1 (R1). LPA reviewed the incident report, and it was learned that on 06/23/2024, during an internal community medication audit, it was noted that (R1)’s Megestrol Acetate 40 mg with directions of take 2 tablets by mouth 2 times daily for 3 weeks was not given to resident from 06/03/2024 to 06/06/2024, 06/12/2024 to 06/20/2024 for a total of 12 days. Furthermore, the incident report dated on 06/29/2024 states that R1 was diagnosed by a home health nurse that they have an unstageable wound on 06/20/2024 at 5:30pm and sent to UC Davis hospital for further evaluation on 06/21/2024. Based on record review, this incident report was faxed to the department on 06/29/2024, however the incident occurred on 06/20/2024 and 06/21/2024. As a result, the facility did not follow the reporting requirements. LPA obtained facility records. Due to insufficient time to review documentation and conduct interviews the department will come at a later date to follow up on the incident reported on 06/29/2024. The following deficiencies were observed and cited from the California Code of Regulations, Title 22, and California Health and Safety Code. The deficiencies can be found on the 809-D page. An exit was interview conducted, and a copy of the 809 report, 809-D page, and appeal rights were given to the facility.

Citations

3 citations recorded*CCLD

What does Type A vs Type B mean?

Type A. Serious citation. Imminent or substantial risk to children. The regulator requires corrective action immediately and may impose a civil penalty.

Type B. Lower-severity citation. Corrective action required, no imminent risk. The regulator monitors compliance on the next visit.

  • 87303(i)(1)(B)Type B

    87303(i)(1)(B) Maintenance and Operation(i) Facilities shall have signal systems which shall meet the following criteria:(1) All facilities licensed for 16 or more and all residential facilities having separate floors or buildings shall have a signal system which shall:(B) Transmit a visual and/or auditory signal to a central staffed location or produce an auditory signal at the living unit loud enough to summon staff. This requirement was not met as evidence by:Based on 7 out 8 resident SMART care log it was learned that residents alert call was not responded to and that occasionally calls took over 15 minutes to respond, which poses a potential health, safety, or personal rights risk to persons in care.

  • 87211(a)(1)Type B

    (a) Each licensee shall furnish to the licensing agency such reports as the Department may require, including, but not limited to, the following:(1) A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence of any of the events specified in (A) through (D) below. This report shall include the resident's name, age, sex and date of admission; date and nature of event; attending physician's name, findings, and treatment, if any; and disposition of the case. This is not met as evidenced by: Based on record review and interview the facility did not report R1's unstageable wound within 7 days of occurence. The incident occured on 06/20/2024 and 06/21/2024 and the facility did not provide the incident report to the department until 06/29/2024. This poses a potential health, safety, and personal rights risks to persons in care.

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  • 87465(a)(4)Type A

    87465 Incidental Medical and Dental Care(a) A plan for incidental medical and dental care shall be developed by each facility. The plan shall encourage routine medical and dental care and provide for assistance in obtaining such care, by compliance with the following:(4) The licensee shall assist residents with self-administered medications as needed. This was not met as evidenced by: Based on record review and interview the Licensee did not ensure that (R1) received (R1) medications as prescribed by (R1)’s physician’s order. The facility did not provide the residents medication prescribed by the doctor from 06/03/2024 to 06/06/2024 and again from 06/12/2024-06/20/2024. This poses an immediate health, safety, and personal rigths risks to persons in care.

FAQ · About this visit

Common questions about this visit

What happened during the July 23, 2024 inspection of OAKMONT OF EAST SACRAMENTO?

This was a other inspection of OAKMONT OF EAST SACRAMENTO on July 23, 2024. 2 citations were issued: 1 Type A (serious) and 1 Type B.

Were any citations issued to OAKMONT OF EAST SACRAMENTO on July 23, 2024?

Yes, 2 citations were issued (1 Type A, 1 Type B). The first citation was for: "87303(i)(1)(B) Maintenance and Operation(i) Facilities shall have signal systems which shall meet the following criteria..."

What type of inspection was this?

This was a other inspection. other inspections are conducted by CCLD as part of their licensing oversight.

SourceView on CCLDView original report

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