Oakmont of Riverpark

§1569.652 Termination of admission agreement upon death of resident... and refunds (c) A refund of any fees paid in advance...shall be issued...to the resident’s estate, within 15 days after the personal property is removed.This requirement is not met as evidenced by Based on interviews and record review, the facility did not comply with the above cited section, as R1 passed away on 10/07/25, belongings were removed on 10/17/25 and check was received on 12/27/25, which poses a potential personal rights risk to persons in care.

87468.2(a)(4)residents…shall have all of the following personal rights: To care, supervision, and services that meet their individual needs and are delivered by staff that are sufficient in numbers, qualifications, and competency to meet their needs.This requirement is not met as evidence by: Based on records review, the licensee did not comply with the section cited above as Staff did not respond to R1’s call for assistance in a timely manner, which posed a potential health and safety risk to residents in care.

87506 Resident Records (a) The licensee shall ensure that a separate, complete, and current record is maintained for each resident in the facility or in a central administrative location readily available ...This requirement is not met as evidenced by: Based on interviews and file review the licensee did not comply with the section cited above as R1's emergency packet was not updated with the resident correct POA information which posed a potential health and safety or personal risk to persons in care.

87303(a)(1) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. (1) Floor surfaces in bath, laundry and kitchen areas shall be maintained in a clean, sanitary, and odorless condition. This requirement is not met as evidenced by:Based on observations and interview, the licensee did not comply with the section cited above as the LPA observed dry feces in R1's bathroom floor which posed a potential health and safety or personal rights risk to persons in care.

87466 Observation of the resident. ... When changes such as unusual weight gains or losses.. are observed, the licensee shall ensure that such changes are documented and brought to the attention of the resident's physician and the resident's responsible person, if any. This requirement is not met as evidenced by: Based on the information gathered via interviews and record review, although the facility’s staff documented R1's weight loss they did not address it with their PCP which posed a potential health and safety risk to persons in care.

Observation of the Resident:The licensee shall ensure that residents are regularly observed for changes in physical, mental, emotional and social functioning and that appropriate assistance is provided when such observation reveals unmet needs.This requirement is not met as evidenced by: Based on the investigation, the licensee did not comply with the section cited above as staff and file review revealed R1 was observed to be declining, and wondering into other residents rooms which posed a potential health and safety risk to residents in care.

87303(a)(1) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. (1) Floor surfaces in bath, laundry and kitchen areas shall be maintained in a clean, sanitary, and odorless condition. This requirement is not met as evidenced by: Based on photos and interviews, the licensee did not comply with the section cited above as R1 was left in their room overnight with fire-extinguisher powder all over the room which posed an immediate health and safety risk to persons in care.

87705(f)(1) Care of Persons with Dementia (f) The following shall be stored inaccessible to residents with dementia: (1) Knives, matches, firearms, tools and other items that could constitute a danger to the resident(s). This requirement is not met as evidenced by: Based on interviews and observation, the licensee did not comply with the section cited above, as R1 had access to fire extinguisher, despite staff knowing that grabbing the fire extinguisher was a known behavior of R1, which posed a potential safety risk to persons in care.

Personal Rights. Residents in all residential care facilities for the elderly shall have all of the following personal rights: To be accorded dignity in their personal relationships with staff,. This requirement was not met as evidenced by: Based on interviews, the licensee did not comply with the section cited above when 6 out of 10 staff are voicing concerns regarding the treatment of the residents by staff which poses an immediate personal rights risk to residents in care.

Personal Rights of Residents(a) Residents in all residential care facilities for the elderly...following personal rights: (8) To have their representatives regularly informed by the licensee of activities related to care or services...This requirement is not met as evidenced by: Based on record review and interviews, licensee did not comply with the above section by failing to inform R1 Responsible party of any change in condition or care needs related to R1, which is a potential

Reporting Requirements: (a) Each licensee shall... reports as the Department may require,...(1)A written report shall be submitted... person responsible...This requirement is not met as evidenced by: Based on interviews and record review, licensee did not comply with the above section by failing to report incidents to the Department and the responsible party involving R1, which is a potential personal rights risk to residents in care.

Based on observation, the licensee did not comply with the section cited above as four out of ten locked resident rooms had disinfectants and or cleaning solutions available within those residents rooms, which poses an immediate health and safety risk to persons in care.

Based on record review, the licensee did not comply with the section cited above as one staff did not have a criminal record clearance, which poses an immediate health and safety risk to persons in care.

87211 Reporting Requirements (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...(D) Any incident which threatens the welfare, safety or health of any resident... This requirement was not met as evidenced by: Based on records review, R1 had multiple falls in July 2022 and was taken for medical care twice due to the falls, however these falls were not reported to CCL, which poses a potential health and safety risk to residents in care.

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:(1) To be accorded dignity in their personal relationships with staff, residents, and other persons.This requirement is not met as evidenced by: Based on interviews with witnesses, staff and management, the licensee did not comply with the section cited above. Staff were observed on their personal phones rather than attending to residents, which poses a potential health and safety risk to residents in care.

87625(b)(3) Managed Incontinence...the licensee shall be responsible for the following: Ensuring that incontinent residents are kept clean and dry and that the facility remains free of odors from incontinence.This requirement is not met as evidenced by: Based on interviews, record review and observation, the licensee did not comply with the section cited above, as they did not ensure residents’ incontinence was properly managed, which poses an immediate health and safety risk to residents in care.

87468.1 Personal Rights of Residents in All Facilities (a)(2) 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 record review and interviews, the licensee did not comply with the section cited above the staff did not respond to R1 and R2's calls for assistance in a timely manner, which poses a potential personal risk to persons in care.

87468.1(a)(3) Personal Rights of Residents in All Facilities. Residents ... shall have all of the following personal rights: To be free from punishment, humiliation, intimidation, abuse, or other actions of a punitive nature ...This requirement is not met as evidenced by: Based on interviews and records review, the licensee did not comply with the section cited above, as S1 restricted R1's movement by pressing their body against R1, which poses a potential personal rights risk to residents in care.

87464(f)(1) 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 and records review, the licensee did not comply with the section cited above. Staff did not supervise R1 which resulted in R1’s fall sustaining a fracture of the right humerus and bruise of the right eye, which posed an immediate health and safety risk to residents in care.

87608 Postural Supports (a) Based on the individual's preadmission appraisal, and subsequent changes to that appraisal, the facility shall provide assistance and care for the resident in those activities of daily living which the resident is unable to do for himself/herself. Postural supports may be used under the following conditions.(5)Under no circumstances shall postural supports include tying, depriving, or limiting the use of a resident's hands or feet.(B) Bed rails that extend the entire length of the bed are prohibited except for residents who are currently receiving hospice care and have a hospice care plan that specifies the need for full bed rails.

87464(f)(1) 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 and records review, the licensee did not comply with the section cited above. Facility did not make use of fall precautions for R1 which resulted in R1 sustaining fall from bed and fracturing right wrist, which posed an immediate health and safety risk to residents in care.

Based on observation, the licensee did not comply with the section cited above in 4 (four) of 10 (ten) water temperature readings taken throughout the building were above the required range reading at 121.7, 123.8, 124.4, and 123.0 degrees Fahrenheit, which poses an immediate safety risk to persons in care.

Based on interview and record review, the licensee did not comply with the section cited above as Staff #1 (S1) has been employed and working in the facility since 11/10/2021 and S1's fingerprint clearance was not associated to the facility, which poses an immediate safety risk to persons in care.

87468.1 Personal Rights of Residents in All Facilities (a)(3) To be free from punishment...or interfering with daily living functions such as eating, sleeping, or elimination.This requirement is not met as evidenced by: Based on interview and record review, the licensee did not comply with the above section, as staff are instructed to wake residents beginning at 4:00AM, which poses an immediate personal rights risk to residents in care.

87468.2 Additional Personal Rights of Residents in Privately Operated Facilities. The licensee shall post the telephone numbers and addresses for the local offices of the ...ombudsman program... conspicuously in the facility foyer, lobby, residents’ activity room, or other location easily accessible to residents This requirement is not met as evidenced by:Based on observation, the licensee did not comply with the section cited above, as the Ombudsman poster was not observed in the memory care unit where memory care residents would be able to observe the poster, which poses a potential health and safety risk to residents in care.

1569.695 Emergency Plans (c) A facility shall conduct a drill at least quarterly for each shift. The type of emergency covered in a drill shall vary from quarter to quarter, taking into account different emergency scenarios. An actual evacuation of residents is not required during a drill. While a facility may provide an...This requirement is not met as evidenced by: Based on interview and record review, the licensee did not comply with the section cited above as quarterly disaster drills were not documented for each shift which posed a potential safety risk to persons in care.

87705 Care of Persons with Dementia (f)(2) The following shall be stored inaccessible to residents with dementia: Over-the-counter medication, nutritional supplements or vitamins, alcohol, cigarettes, and toxic substances such as certain plants, gardening supplies, cleaning supplies and disinfectants.This requirement is not met as evidenced by: Based on LPA's observations and record review, the licensee did not comply with the section cited above as toxic substances were observed accessible to residents which poses an immediate health risk to persons in care.

87705 Care of Persons with Dementia(f)(1) The following shall be stored inaccessible to residents with dementia: Knives, matches, firearms, tools and other items that could constitute a danger to the resident(s).This requirement is not met as evidenced by: Based on LPA's observations and record review, the licensee did not comply with the section cited above as S1's medication was observed accessible to residents which poses an immediate health risk to persons in care.

87705 Care of Persons with Dementia (f)(2) The following shall be stored inaccessible to residents with dementia: Over-the-counter medication, nutritional supplements or vitamins, alcohol, cigarettes, and toxic substances such as certain plants, gardening supplies, cleaning supplies and disinfectants.This requirement is not met as evidenced by: Based on LPA's observations, the licensee did not comply with the section cited above as laundry detergent was accessible to residents which poses an immediate health and safety risk to persons in care.

87464 Basic services (f)(1)(c) "Care and supervision" means the facility assumes responsibility for, or provides or promises to provide in the future, ongoing assistance with activities of daily living without which the resident’s physical health, mental health, safety, or welfare would be endangered.This requirement is not met as evidenced by: Based on interviews and record review, the licensee did not comply with the section cited above as R1 left the facility unassisted which poses an immediate health and safety risk to persons in care.