Oakmont Of North Fresno

Report on file with the state — no findings text was published for this visit. The complete document is on the state’s site.

Report on file with the state — no findings text was published for this visit. The complete document is on the state’s site.

Report on file with the state — no findings text was published for this visit. The complete document is on the state’s site.

Report on file with the state — no findings text was published for this visit. The complete document is on the state’s site.

Report on file with the state — no findings text was published for this visit. The complete document is on the state’s site.

Report on file with the state — no findings text was published for this visit. The complete document is on the state’s site.

Report on file with the state — no findings text was published for this visit. The complete document is on the state’s site.

Report on file with the state — no findings text was published for this visit. The complete document is on the state’s site.

Report on file with the state — no findings text was published for this visit. The complete document is on the state’s site.

Allegation investigated: Staff do not ensure resident's hygiene needs are being met Staff do not ensure resident's grooming needs are being met

Licensing Program Analyst (LPA) Katie Brown arrived unannounced to conduct the initial complaint investigation at the facility. LPA met with and explained the reason for the visit with Martin Valenzuela (S1). Administrator (AD) Heidi Setty was contacted and authorized S1 to meet with LPA and sign the report. During this visit, LPA Conducted a record review, interviewed staff, toured resident apartments in Memory Care (MC) and observed residents in common areas of the MC wing of the facility. This Department investigated the allegations above: Resident (R1’s) Service Plan dated 4/19/25 states R1 requires standby assistance with set up for grooming and other hygiene related Activities of Daily Living (ADL) and R1 often refuses care and assistance. R1’s grooming and hygiene items were observed in R1’s room. Interview with staff confirm R1 often does not want to brush teeth or take a shower. Pictures of R1’s teeth were submitted for the purpose of this investigation. Based on interview andthe state’s words, verbatim · CDSS document, Sep 12, 2025 · control 24-AS-20250905082923

Allegation investigated: Staff won't allow resident to talk on the phone

Licensing Program Analyst (LPA) Katie Brown arrived unannounced to conduct the initial complaint investigation, LPA met with and explained the reason for the visit and the allegation with Administrator (AD) Heidi Setty. Complaint findings were delivered during this visit. During the visit, LPA obtained resident file documents and conducted staff and resident interviews. Staff interviews were consistent; Memory care residents have access to a community phone and staff assist them to use it when transferred by the front desk. Resident (R1) receives calls and uses the phone often. R1 also chooses not to take calls at times. When asked about receiving phone calls, R1 answered, "yes". This Agency has investigated the allegation listed above. We have found that the allegation is UNFOUNDED, therefore we have dismissed the allegation. There were no citations issued. An exit interview was conducted, and a copy of this report was provided. Unfoundedthe state’s words, verbatim · CDSS document, Aug 15, 2025 · control 24-AS-20250806105545

Allegation investigated: Staff leave resident soiled causing skin rash Staff do not follow Physician's Orders Staff do not ensure resident's hygiene needs are met Staff do not allow resident visitation

Licensing Program Analyst (LPA) Katie Brown arrived at the facility unannounced to conduct a subsequent complaint visit and deliver complaint findings. LPA met with and explained the reason for the visit with Administrator (AD) Heidi Setty. During the visit, LPA observed Resident (R1) in the common area. LPA observed R1's apartment, conducted interviews and reviewed records. The Department investigated the allegations listed above: Staff leave resident soiled causing skin rash: Per Service Plan dated 4/19/25 R1 uses incontinence supplies and frequently refuses staff assistance with care including toileting and bathing. Review of Medication Record reveals that R1 refuses taking medications including use of tpoical creams often. Staff interviews have conflicting reporting on R1's compliance with activities of daily living. See LIC9099C for continuation of this report Unsubstantiatedthe state’s words, verbatim · CDSS document, Jul 14, 2025 · control 24-AS-20250430083718

Allegation investigated: Facility does not ensure Physician ordered diets and restrictions were followed

Licensing Program Analyst (LPA) Katie Brown arrived at the facility unannounced to conduct the initial complaint investigation. LPA spoke to Administrator (AD) Heidi Setty on the phone during the visit. LPA met with and explained the reason for the visit and the elements of the allegations with Marketing Director, Mary Davis. LPA delivered investigation findings to the facility during this visit. This Department investigated the allegation: Facility does not ensure Physician ordered diets and restrictions are followed. Staff interviews were conducted which revealed the facility procedure for communication with chef/kitchen staff. Record Review of Resident Dietary Information was conducted and LPA observed dinner being served in Memory Care. Specific resident information was not provided. Based on interview and record review the above allegations are UNSUBSTANTIATED. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove that the allegedthe state’s words, verbatim · CDSS document, Jul 1, 2025 · control 24-AS-20250627110501

Report on file with the state — no findings text was published for this visit. The complete document is on the state’s site.

Report on file with the state — no findings text was published for this visit. The complete document is on the state’s site.

Allegation investigated: Staff left resident in soiled undergarments for an extended period of time Staff did not ensure resident's grooming needs are being met

Licensing Program Analyst (LPA) Katie Brown arrived unannounced to deliver investigation findings. LPA met with and explained the reason for the visit with Administrator (AD) Heidi Setty. This department investigated the allegation: Staff left resident in soiled undergarments for an extended period of time. Record review of R1's care plan and interviews confirm that Resident R1 is independent in toileting and prefers to wear disposable underware. R1 is not on a toileting program though staff offer to assist R1 who often refuses the help. This department investigated the allegation: Staff did not ensure resident's grooming needs are being met. R1 was observed on 9/25/24 and 2/3/25 to be well groomedd, and wearing clean clothess. R1's personal grooming items were also observed on the dates above. An interview with the facility podiatrist confirms that the Dr, attempts to provide treatment with each visit and R1 usually refuses. It was confirmed that the podiatrist visits are covered by Rthe state’s words, verbatim · CDSS document, Feb 3, 2025 · control 24-AS-20240920162946

Report on file with the state — no findings text was published for this visit. The complete document is on the state’s site.

Report on file with the state — no findings text was published for this visit. The complete document is on the state’s site.

Allegation investigated: Resident fell due to staff neglect Staff did not prevent resident from wandering from the facility Facility did not report a resident fall

Licensing Program Analyst(LPA) Katie orwn arrived at the facility unannounced to deliver the complaint findings. LPA met with Administrator (AD) Heidi Setty. The Department investigated the allegations listed above. Interviews and record review of R1’s hospice care plan and facility documentation reveal that on 3/10/23, R1’s hospice care plan was not followed resulting in R1 falling while being assisted by hospice aid and facility care staff. The care plan (certification period 2/3/23 – 3/30/23) notes that R1 will receive a bed bath. On 10/10/22, Resident (R2) was located by staff after exiting the facility resulting in Absence Without Leave (AWOL). R2 was found walking down the street off facility grounds. R2’s Physician’s Report dated 4/29/22 states R2 cannot leave the facility unassisted. See Lic9099C for continuation of this report Substantiatedthe state’s words, verbatim · CDSS document, Jan 12, 2024 · control 24-AS-20230911151045

Allegation investigated: Lack of Care and/or supervision Personal Rights Staff does not safeguard resident's personal belongings Staff does not record resident's medicaitons in log General Food Service Requirements

Licensing Program Analyst (LPA) Katie Brown arrived at the facility unannounced to conduct a subsequent complaint visit and deliver investigation findings to the facility. LPA explained the reason for the visit with Administrator (AD) Heidi Setty. During this visit, LPA observed Resident (R1's) apartment and lunch dining service. LPA also conducted interviews and obtained documents from R1's facility file for record review. The Department conducted an investigation of the allegations stated above. Interview and record review reveal that R1's inventory list,has been maintained by a family member, not the facility. R1's apartment was toured on 8/9/23, 8/17/23, 11/16/23 and 12/12/23 where blankets, towels and a clean couch cover were observed. Soiled clothing was not observed in R1's closet or drawers on these dates. There are not Housekeeping records to indicate that services were or were not provided as reported. Based on interviews, R1's room and personal items are cleaned up daily tothe state’s words, verbatim · CDSS document, Dec 12, 2023 · control 24-AS-20230809115225

Report on file with the state — no findings text was published for this visit. The complete document is on the state’s site.

Allegation investigated: Personal Rights Lack of care and/or supervision Violations related to Maintenance and Operation Violations related to Incidental Medical and/or Dental Care Training Requirements

Licensing Program Analyst (LPA) Katie Brown arrived at the facility unannounced to conduct a subsequent complaint investigation. LPA met with Memory Care Director (MCD) Andrea Yescas. During this visit, LPA conducted resident interviews and reviewed staff records. The Department investigated the allegations ablove. LPA conducted multiple visits to the facility during the course of this investigation. R1 was observed each time to be clean and in clean clothing. During these visits, R1 was observed using the public telephone, watching television, participating in group activities or eating in the dining room. R1's room and bathroom were clean during LPA visits. Photos were provided of a brown substance which may have been feces on the toilet and surrounding areas. Staff interviewed state that this may occur due to R1 and R2 using the toilet independently without being able or aware of sufficient cleaning. LPA observed the chairs, tables and floors of the dining room to be clean during vithe state’s words, verbatim · CDSS document, Nov 16, 2023 · control 24-AS-20230808141453

Allegation investigated: Licensee did not abide by the terms of resident’s admission agreement.

Licensing Program Analyst (LPA) Katie Brown arrived at the facility unannounced to conduct the initial 10-Day complaint investigation. Upon entry, LPA met with Marketing Director (MD) Mary Davis. Administrator (AD) Heidi Setty and Health Services Director (HSD) Nathaniel Domingues arrived shortly after. LPA explained the reason for the visit and the elements of the allegation. During the visit, LPA conducted record review of Resident (R1's) file as well as interviewed AD and HSD. Interviews reveal a discrepancy in whether proper notification of physician ordered lab work was communicated to R1’s Responsible Party. Facility charting notes and shift report document that a message was left by staff. Interview and record review of the Residence and Service Agreement (RSA) reveal that pharmacy designation is part of the admission process but not an element of the RSA. See Lic9099-C for continuation of this report Unsubstantiatedthe state’s words, verbatim · CDSS document, Nov 16, 2023 · control 24-AS-20231114150812

Allegation investigated: Staff mismanaged resident's medications.

Licensing Program Analyst (LPA) Katie Brown arrived at the facility unannounced to conduct a subsequent complaint visit. Administrator (AD) was not at the facility for the visit. LPA met with and explained the reason for the visit with Marketing Director (MD)Mary Davis. During the visit, LPA obtained additional documents from Resident (R1’s) file and conducted a record review.The Department investigated the allegation above. LPA conducted a record review of R1’s Facility Chart Notes, Centrally Stored Medication & Destruction Record (CSMDR) and Medication Administration Records (MAR) during the timeframe of April - August 2023. Based on record review, it was identified that the CSMDR for R1 was not maintained resulting in inaccurate documentation and medication counts. The preponderance of evidence standard has been met, therefore the above allegations are found to be SUBSTANTIATED. A deficiency is being cited in accordance with California Code of Regulations on the attached LIC 9099-D.the state’s words, verbatim · CDSS document, Nov 6, 2023 · control 24-AS-20230801083339

Allegation investigated: Facility has insufficient staffing to meet residents’ needs Staff leave resident unattended for extended periods of time Staff failed to provide a safe and comfortable environment for resident Facility is malodorous

Licensing Program Analyst (LPA) Katie Brown arrived unannounced to conduct a subsequent complaint visit and deliver investigation findings to the facility. LPA met with and explained the reason for the visit with Administrator (AD) Heidi Setty. The Department has investigated the allegations listed above. LPA observed Resident (R1) and R1's room which was found to be clean and odor free on 7/6/23 and 10/16/23. Furniture and assistive devices were stored appropriately and neatly. R1 was observed clean and resting comfortably in bed. LPA observed R1 properly positioned during meals. During this visit, LPA conducted staff and Hospice Nurse interviews. LPA reviewed R1's file including facility's daily Staff Assignment Log for June - October 2023, Housekeeping and staff schedules were also reviewed. Based on observation, interview and record review, the above allegations are UNSUBSTANTIATED. Although the allegatiosn may have happened or are valid, there is not a preponderance of evidence tothe state’s words, verbatim · CDSS document, Oct 16, 2023 · control 24-AS-20230630095305

Allegation investigated: Facility staff do not provide adequate assistance to resident in care. Resident room is malodorous.

Licensing Program Analyst (LPA) Katie Brown arrived unannounced to conduct the initial 10-Day complaint visit. LPA met with and explained the reason for the visit with Administrator (AD) Heidi Setty. During the visit LPA observed R1's room. R1 was observed clean and resting comfortably in bed. LPA observed R1 again during lunch and interviewed R1. R1's room and bathroom were odor free during the visit. LPA conducted staff and Hospice Nurse interviews and reviewed R1's file. LPA reviewed Staff Assignment sign off sheets for August, September and October 2023. Based on the above, the above allegation is UNSUBSTANTIATED. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove that the alleged violation did or did not occur. There were no citations issued An exit interview was conducted and a copy of this report was left with AD, whose signature confirms receipt of these documents. Unsubstantiatedthe state’s words, verbatim · CDSS document, Oct 16, 2023 · control 24-AS-20231010161832

Report on file with the state — no findings text was published for this visit. The complete document is on the state’s site.

Report on file with the state — no findings text was published for this visit. The complete document is on the state’s site.

Report on file with the state — no findings text was published for this visit. The complete document is on the state’s site.

Allegation investigated: The facility did not conduct an assessment of resident prior to returning from the hospital with a change of condition

Licensing Program Analyst (LPA) Katie Brown arrived at the facility to deliver complaint investigation findings. LPA met with Administrator (AD) Heidi Setty. Resident (R1) fell resulting in a fracture requiring surgery on 5/1/23. Based on interview, it was confirmed that the facility did not conduct an assessment or obtain required updated documentation of R1’s changes in condition or care needs prior to return to the facility on 5/6/23. Deficiencies are being cited in accordance with California Code of Regulations on the attached LIC 809-D. An exit interview was conducted and Plan of Correction was developed. A copy of this report and Appeal Rights were discussed and left with AD, whose signature on this form confirms receipt of these documents. Substantiatedthe state’s words, verbatim · CDSS document, Aug 30, 2023 · control 24-AS-20230516174446

Allegation investigated: The facility did not conduct an assessment of resident prior to returning from the hospital with a change of condition

Licensing Program Analyst (LPA) Katie Brown arrived at the facility to deliver complaint investigation findings. LPA met with Administrator (AD) Heidi Setty. Resident (R1) fell resulting in a fracture requiring surgery on 5/1/23. Based on interview, it was confirmed that the facility did not conduct an assessment or obtain required updated documentation of R1’s changes in condition or care needs prior to return to the facility on 5/6/23. The preponderance of evidence standard has been met, therefore the above allegations are found to be SUBSTANTIATED. Deficiencies are being cited in accordance with California Code of Regulations on the attached LIC 809-D. An exit interview was conducted and Plan of Correction was developed. A copy of this report and Appeal Rights were discussed and left with AD, whose signature on this form confirms receipt of these documents. Substantiatedthe state’s words, verbatim · CDSS document, Aug 30, 2023 · control 24-AS-20230516174446