Correction check·September 4, 2025

Licensing Program Analyst (LPA) Christi Coppo arrived at this facility unannounced, to conduct a Case Management visit. LPA was greeted by concierge. Sanjay Kabadi, Administrator was unavailable but greeted LPA later. On 7/17/25 LPA issued citations for deficiencies of regulations: Health and Safety Code (HSC)1569.269(a)(6), CCR 87465(h)(5), and CCR 87465(a)(4). The plan of correction for HSC1569.269(a)(6) required facility to submit plan to CCL to conduct personal rights training and training for all direct care staff on prompt call/pendant response times by plan of correction due date. Training to be conducted through facility's chosen vendor, Relias as well as an in-service training by no later than 8/7/25. The plans of correction for deficiencies of CCR 87465(h)(5) and 87465(a)(4) required facility to submit plan to conduct in-service training on pre-pouring medication and medication administration training by plan of correction due date. In-service training to be conducted no later than 8/7/25. Additionally, facility to submit written procedure plan to conduct daily audit of medication closet and medication cart to ensure staff are not pre-pouring medications, by no later than 8/7/25. On 7/18/25, Health Services Assistant (HSA) Pam Brown submitted required plans for these deficiencies. However, as of today, CCL has not received the in-service training logs nor the Relias training records required for the plan of correction. So, these deficiencies are being re-cited today ( deficiencies cited, see 809D ). During visit, LPA found medication room unattended, unlocked, and with medication bubble pack accessible to residents ( deficiency cited, see 809D ). Continued on 809C... Continued from 809... LPA also observed Centrally Stored Medication closet to contain a rainbow medi-set pillbox with medications present, giving the appearance of pre-pouring. Per LPA interview with Jody Livingston, Health and Wellness director (HWD) facility has stopped pre-pouring. She explained that the medications found were not pre-poured but rather were medications given to the facility by a resident. The pillbox was waiting to be destroyed because the pills were not labeled and it is Oakmont Gardens' policy that any medication not in a pharmacy bottle is not acceptable. HWD emphasized to LPA that in her view, the medication pillbox was not in rotation and was in the overflow section of the medication closet such that they would not be confused with any medications being given to residents. No citation issued today; however, LPA discussed with HWD facility's compliance history with pre-pouring medications and that today's appearance of pre-pouring is out of compliance with regulation. LPA advised that all medications needing to be destroyed should be destroyed immediately. HWD agreed and expressed to LPA that going forward all medications needing to be destroyed will be destroyed immediately. Additionally, during visit, LPA observed black and white fuzzy substance inside exposed walls in hallway by rooms #113-#116 which appears wet, dark in color, and has the odor of mildew. Insides of walls are exposed as well as some portions of the ceiling, exposing pipes in the wall and in the ceiling. Holes in wall were observed to be on the corner of the hallway by room#116, in the ceiling by room #116 and at the end of the hallway by room #113. Exposed portions of walls are covered by a thin clear piece of film held up by pieces of tape. Exposed portions of ceiling are not covered. LPA observed odor of mildew to be strongest at the end of the hallway by room #113. Black and white fuzzy substance that appears wet and dark in color and has the odor of mildew is accessible to residents and film covering hole does not appear to mitigate any potential airborne health hazards. LPA observed exposed inner portion of wall on the corner by room #116 to have discoloration coming from the appearance of recently being covered with paint ( deficiency cited, see 809D ). LPA spoke to Asst Maintenance person (S1), who explained to LPA that when railing was installed in this hallway whomever did the installation must have damaged the pipes in the wall in that location because beginning Thursday, 8/29/25 moisture was noticeably collecting and pooling at the bottom of the wall. Once the moisture was observed, facility maintenance cut open the wall to find the leaking pipes, as well as the ceiling. The leak was found and now facility is waiting for plumber to arrive and fix the leaks. Continued on 809C(2)... Continued from 809C... While at facility, LPA also followed up on Incident Reports submitted to CCL on 8/29/25 for residents R1, R2, and R3, each of these residents had experienced a fall but refused emergency medical services (EMS). Incident Report for R1, indicated R1 complained of headache but denied hitting their head, R2 was found on the floor face down but also denied hitting their head, and R3 stated they did hit their head. However, each of these residents refused EMS. LPA discussed incidents with HWD. LPA discussed the importance of getting potential head injuries assessed by a medical professional. LPA explained that it is aresident's right to refuse EMS, but the facility must document each instance of resident refusal. HWD advised LPA that facility does document all resident refusals for EMS. However, HWD could not produce documented refusals for LPA. LPA also discussed with HWD that if a resident has a behavioral expression of cognitive impairment, then best practices are that EMS should be called to assess resident. Additionally, if a residents' family member expresses their wish for EMS not to be called, to maintain compliance with regulation, facility is required to call EMS. Deficiencies cited from the California Code of Regulations, Title 22, Division 6 of California Regulation and the Health and Safety Code. Appeal rights given and discussed with Administrator. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties. Exit interview conducted with Administrator and a copy of this report was given .