Inspection visit

complaintAugust 29, 2023

Clean visit · 0 citations

Inspector’s narrative

What the inspector wrote

Multiple relevant parties reported to the Department varying accounts of medication mismanagement by facility staff. LPA reviewed an internal document indicating that, on 1/1/2023 during a medication audit, it was found that a medication that was supposed to be given to a resident was not in the medication bin. Through more investigation, it was determined that the medication was reviewed and approved by Memory Care Director (MCD), Belinda Prunty, and listed to be “injected” even though the facility does not have injectable medication that they can administer. It was documented that MCD did not check to see if medication was at the facility and records indicated that medication had been marked as “given” by other med-techs. During a visit conducted on 5/17/2023, LPAs Michael Hood and Angela Hood conducted a medication count for residents R1 and R2, comparing each resident’s Centrally Stored Medication Form (CSM) with medications centrally stored for the resident. LPAs observed three (3) medications for R2 that were off count in relation to what was documented. All three medications that were off count were over the amount documented. Facility was able to account for 1 day (4/29/2023) in which R2 was out of the facility, but no other refusals were documented that could account for the amount over what was documented. Due to facility receiving a citation regarding the same violation in a separate inspection conducted on 8/29/2023, no additional citations will be issued regarding allegation. Multiple relevant parties reported to the Department that facility staff are not assisting residents with bathing. Interview with resident (R3) indicated that they went 5 to 6 weeks without a shower when they were requesting to have a shower. Resident Assessments for R3 dated 9/19/2022, 10/2/2022, 11/20/2022, and 4/13/2023 all indicated that R3 requires hands-on assistance for all showering/bathing needs 1 to 2 times a week. ** Report continued on 9099-C ** Interview with ED indicated that the facility required R3 to obtain a shower chair due to 2 person assist transfers no longer being safe for resident regarding showers. ED stated that R3 went without a shower for 30 days before obtaining a shower chair that R3 did not find comfortable, and another 30 days without a shower to obtain a different shower chair that worked for R3. During this time, R3 was obtaining bed baths from staff. ED stated that R3 was admitted with a hoyer lift to assist with transfers, but R3 refused to use the hoyer lift due to it being uncomfortable for resident. ED stated that R3 personally made the order for the shower chair and was not provided by the facility. Resident Assessments dated 9/19/2022, 10/2/2022, and 11/20/2022 for R3 indicated that resident required a two-person assist with the use of a mechanical lift. Resident Assessment dated 4/13/2023 for R3 indicated that R3 “requires two-person physical assistance with transfers.” LPA reviewed R3's Physician's Report for RCFE LIC 602A dated 8/8/2022 and observed R3 was in need of assistance with bathing. LPA reviewed R3's Preplacement Appraisal Information (LIC 603) and observed R3 needs services for bathing. Resident Assessments for R3 dated 9/19/2022, 10/2/2022, 11/20/2022, and 4/13/2023 all indicated that R3 requires hands-on assistance for all showering/bathing needs 1 to 2 times a week. LPA reviewed the facility’s shift notes from April 2023 to August 2023 and Staff Assignments by Month by Unit for R3 from May 2023 to August 2023. LPA observed only 1 bed bath documented for 6/1/2023 for the month of June 2023. All other entries for June 2023 were blank and not documented as given. Bed baths and showers for R3 were documented inconsistently for the months of April 2023 and May 2023, with some weeks not having any bed baths or showers documented. ED was unable to provide any additional documentation regarding R3's bathing. Due to facility receiving a citation regarding the same violation in a separate inspection conducted on 8/29/2023, no additional citations will be issued regarding allegation. Based on interviews conducted, a medication count, and records reviewed, the preponderance of evidence standards have been met. Therefore, the above allegations are found to be SUBSTANTIATED. Per California Code of Regulations, Title 22, Division 6, Chapter 8, deficiencies were cited during a separate inspection conducted on 8/29/2023 regarding the same violations. Exit interview was conducted with ED. A copy of this report and appeal rights were provided. ED's signature on these forms acknowledges receipt of these documents.

Citations

7 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.

1569.625(b)(1Type B
§1569.625 Staff training; legislative findings; contents (b) (1) The department shall adopt regulations to require staff members of residential care facilities for the elderly who assist residents with personal activities of daily living to receive appropriate training. This training shall consist of 40 hours of training. A staff member shall complete 20 hours, including six hours specific to dementia care, as required by subdivision (a) of Section 1569.626 and four hours specific to postural supports, restricted health conditions, and hospice care, as required by subdivision (a) of Section 1569.696, before working independently with residents. The remaining 20 hours shall include six hours specific to dementia care and shall be completed within the first four weeks of employment. The training coursework may utilize various methods of instruction, including, but not limited to, lectures, instructional videos, and interactive online courses. The additional 16 hours shall be hands-on training. (2) In addition to paragraph (1), training requirements shall also include an additional 20 hours annually, eight hours of which shall be dementia care training, as required by subdivision (a) of Section 1569.626, and four hours of which shall be specific to postural supports, restricted health conditions, and hospice care, as required by subdivision (a) of Section 1569.696. This training shall be administered on the job, or in a classroom setting, or both, and may include online training. This requirement is not met as evidenced by: Based on records reviewed, facility did not ensure that staff were acquiring all required trainings per Health and Safety Code, which poses a potential health, safety, and personal rights risk to residents 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 (...) by compliance with the following: (4) The licensee shall assist residents with self-administered medications as needed. This requirement is not met as evidenced by: Based on medication counts and records reviewed, the facility did not ensure that resident R1 was receiving medications as prescribed, which poses an immediate health, safety, and personal rights risk to residents in care.
87618(b)(3)(B)Type B
87618 Oxygen Administration - Gas and Liquid (b) In addition to Section 87611(b), the licensee shall be responsible for the following: (3) Ensuring that the use of oxygen equipment meets the following requirements: (B) "No Smoking-Oxygen in Use" signs shall be posted in the appropriate areas. This requirement is not met as evidenced by: Based on observations, the facility did not ensure that "No Smoking-Oxygen in Use" sign was posted on every apartment door with a resident using oxygen, which poses a potential health, safety, and personal rights risk to residents in care.
87465(a)(1)Type A
87465 Incidental Medical and Dental Care (a) A plan for incidental medical and dental care shall be developed (...): (1) The licensee shall arrange, or assist in arranging, for medical and dental care appropriate to the conditions and needs of residents. This requirement is not met as evidenced by: Based on interviews conducted and records reviewed, the facility did not ensure resident R1 received medical attention regarding pressure injuries, resulting in the development of unstageable pressure injuries, which poses an immediate health, safety, and personal rights risk to the residents in care.
87466Type A
87466 Observation of Resident - The licensee shall ensure that residents are regularly observed for changes in physical (...) functioning and that appropriate assistance is provided when such observation reveals unmet needs. (...) This requirement is not met as evidenced by: Based on interviews conducted and records reviewed, the facility did not ensure resident R1 received proper care and assistance when pressure injuries were observed by staff, which poses an immediate health, safety, and personal rights risk to the residents in care.
87464(f)(1)Type B
87464 Basic Services (f) Basic services shall at a minimum include: (1) Care and supervision as defined in Section 87101(c)(3) and Health and Safety Code section 1569.2(c). This requirement is not met as evidenced by: Based on interviews conducted and records reviewed, the facility did not ensure resident R1 was receiving incontience care and shower assistance, which poses a potential health, safety, and personal rights risk to the residents in care.
87468.1(a)(2)Type B
87468.1 Personal Rights of Residents in All Facilities (a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (2) To be accorded safe, healthful and comfortable accommodations, furnishings and equipment. This requirement is not met as evidenced by: Based on interviews conducted and records reviewed, the facility did not ensure resident R1 received a shower chair timely to assist with providing incontinence care and shower assistance, which poses a potential health, safety, and personal rights risk to the residents in care.

FAQ · About this visit

Common questions about this visit

What happened during the August 29, 2023 inspection of OAKMONT OF FAIR OAKS?

This was a complaint inspection of OAKMONT OF FAIR OAKS on August 29, 2023. The inspection found no deficiencies and no citations were issued.

Were any citations issued to OAKMONT OF FAIR OAKS on August 29, 2023?

No citations were issued during this inspection. The facility was found to be in compliance with all applicable regulations.

What type of inspection was this?

This was a complaint inspection. Complaint inspections are triggered when someone reports a concern about the facility to CCLD.

SourceView on CCLD View original report

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Data from CCLD public records. Last updated May 25, 2026. If you believe any information is inaccurate, report it here.

complaint·August 29, 2023