Oakmont Of East Sacramento

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 residents’ incontinent care needs are being met Staff do not allow residents to eat their meals in a comfortable manner Staff do not ensure residents are treated with dignity and respect regarding their health conditions

On 08/22/025, Licensing Program Analyst (LPA) Pang Lee arrived unannounced to this facility to conduct a complaint visit. LPA met with Executive Director/Administrator Kathleen Gilbey and explained the purpose of the visit. The purpose of this visit is to deliver complaint findings for the above allegations. The current census is 150. It was alleged that staff do not ensure residents incontinent care needs are being met. The investigation included interviews with staff, residents, responsible parties, and direct observations. LPA Lee interviewed all 5 facility staff members, all of whom denied that residents’ incontinence care needs are not being met. According to staff interviews, residents are checked, changed, and encouraged to use the toilet every two hours. CONTINUED LIC 9099-C Unsubstantiatedthe state’s words, verbatim · CDSS document, Aug 22, 2025 · control 27-AS-20250728104736

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 did not keep the facility free from bug infestation. Staff did not ensure a resident had sufficient clothing .

On 1/14/2025, Licensing Program Analyst (LPA) Arielle Pascua arrived unannounced to this facility to conduct a complaint visit. LPA met with Facility Designated Administrator (FDA), Kathleen Gibley and explained the purpose of the visit. The purpose of this visit was to deliver complaint findings for the allegations above. Current census was 140. A brief interview with FDA Gibley was conducted. Allegation: Staff did not keep the facility free from bug infestation It was alleged that facility staff did not keep the facility free from bug infestation. During the course of this investigation, LPA reviewed facility records and conducted interviews. Based on interviews conducted, it was learned that in August 2024 the facility noticed that there was a bed bug in a room on the second floor. Immediately facility staff called Eco Lab to treat the affected apartment. It was stated that Eco Lab also inspected the apartments on both sides of the affected apartment as well as apartment above the athe state’s words, verbatim · CDSS document, Jan 14, 2025 · control 27-AS-20241029092509

Allegation investigated: Staff does not respond to residents call pendant in a timely manner.

On 07/23/2024 at 9:30, Licensing Program Analysts (LPAs) Pang Lee and Arielle Pascua arrived unannounced to this facility to conduct a complaint visit. LPA met with administrator Kathleen Gilbey and explained the purpose of the visit. The purpose of this visit is to deliver complaint finding for the allegation above. The current census is 135. A brief interview with conducted with the administrator. Allegation: Staff does not respond to residents’ call pendant in a timely manner. It was alleged that staff does not respond to resident(s) call pendant in a timely manner. This investigation consisted of records reviewed, interviews with staff and residents. LPA Lee interviewed 4 out of 9 residents who has concern regards to staff not responding to resident’s call pendant in a timely manner. LPA Lee requested and reviewed 8 residents SMART care log. It was learned that 7 out of 8 SMART care log resident’s alert was not responded; therefore, it is unclear if residents receive the support ththe state’s words, verbatim · CDSS document, Jul 23, 2024 · control 27-AS-20240520110159

Allegation investigated: Staff are not assisting resident with showers Staff did not ensure the residents blood glucose testing equipment was working properly Staff did not ensure residents medication was reordered timely causing the resident to miss medication

On 07/23/2024, Licensing Program Analysts (LPAs) Arielle Pascua and Pang Lee arrived unannounced to this facility to conduct a complaint visit. LPAs met with Facility Designated Administrator (FDA), Kathleen Gilbey and explained the purpose of the visit. The purpose of this visit was to deliver complaint findings for the allegations above. Current census was 135. A brief interview with FDA Gilbey was conducted. Allegation: Staff are not assisting resident with showers. It was alleged that the staff are not assisting a resident with showers. During the course of this investigation, this LPA reviewed facility records and conducted staff and resident interviews. Based on facility records, R1 moved into the facility on 06/30/2023. On 06/30/2023, the faciltiy conducted a pre-assessment for R1 that only stated that this resident needed care for a special diabetic diet, fall risk program, and assistance with completion of insurance claim forms. A review of the facilities periodic assessmentsthe state’s words, verbatim · CDSS document, Jul 23, 2024 · control 27-AS-20240425082151

Allegation investigated: Facility did not prevent resident from making inappropriate comments to other residents.

On 07/23/2024, Licensing Program Analysts (LPAs) Arielle Pascua and Pang Lee arrived unannounced to this facility to conduct a complaint visit. LPAs met with Facility Designated Administrator (FDA), Kathleen Gibley and explain the purpose of the visit. The purpose of this visit was to deliver complaint findings for the allegations above. Current census was 135. A brief interview with FDA Gibley was conducted. It was alleged that the facility did not prevent a resident from making inappropriate comments to other residents. During the course of this investigation this LPA reviewed facility records and conducted interviews with staff and residents. A interview with 9 residents were conducted. 9 out of 9 residents state that they do not have any issues with any residents. 9 out 9 residents state they have not witnesed any residents speaking inappropriately with other residents. 9 out 9 residents deny having said any inappropriate comments to other residents. An interview with 5 staff membethe state’s words, verbatim · CDSS document, Jul 23, 2024 · control 27-AS-20240508105359

Allegation investigated: Staff did not safeguard resident’s personal belongings

THIS IS AN AMENDED VERSION OF THE ORIGINAL REPORT CREATED ON 07/23/2024. On 07/23/2024 at 10:30 AM, Licensing Program Analysts (LPAs) Pang Lee and Holly Williams arrived unannounced to this facility to conduct a complaint visit. LPA met with Assistant Executive Juliann Owens and explained the purpose of the visit. The purpose of this visit is to deliver complaint finding for the allegation above. The current census is 135. A brief interview with conducted with the Juliann Allegation: Staff did not safeguard resident’s personal belongings It was alleged that staff did not safeguard resident’s personal belongings. This investigation consisted of records reviewed and interviews with staff. It was learned that resident 1 (R1) did not want to inventory personal property. On 04/24/2024 administrator Kathleen Gilbey stated that (R1)’s glasses were safeguarded since it was not lost but were in (R1)’s room and that a facility staff notice that (R1)’s glasses were broken; therefore, the facilitythe state’s words, verbatim · CDSS document, Jul 23, 2024 · control 27-AS-20240419093805

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: ) Neglect/Lack of Supervision: Resident sustained a fracture due to lack of care from staff 2) Other: Facility call system is in disrepair 3) Reporting Requirements: Staff did not inform resident's authorized person of resident's hospitalization

Licensing Program Analysts (LPA) Kevin Gould made an announced inspection to the Oakmont of East Sacramento RCFE on 3/20/24 at 9:00am to conclude the investigation of the above allegations and to deliver the findings. LPA Gould met with Administrator, Kathleen Gilby and together discussed the investigation details. Based on the interviews and statements obtained during the investigation process, the allegations are determined to be substantiated. Regarding allegations that resident sustained an injury due to lack of care from staff, the Department conducted interviews with seven staff members and S1, S3, S5 and S7 (See confidential name list LIC-811 dated 3/20/24) all provided statements to the department that R1 being a fall risk and having multiple falls while at the facility. A1 and A2 statements revealed that the facility failed to provide R1 with a fall prevention plan. A2 provided several emails to S2 and S3 regarding R1's alert pendant not working properly and concerns to addresthe state’s words, verbatim · CDSS document, Mar 20, 2024 · control 27-AS-20230921115438

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 respond to resident(s) call bells in a timely manner.

On 10/24/2023 at 1:15 PM, Licensing Program Analyst (LPA) Pang Lee arrived unannounced to this facility to conduct a complaint visit. LPA met with administrator, Luis Olivas and explained the purpose of the visit. The purpose of this visit is to deliver complaint finding for the allegation above. The current census is 147. A brief interview conducted with administrator, Luis Olivas. Allegation: Staff do not respond to resident(s) call bells in a timely manner. It was alleged that Staff does not respond to resident(s) call bells in a timely manner. This investigation consisted of records reviewed, interviews with staff, residents, and the resident responsible party. LPA Lee interviewed 7 out of 10 residents who has a concern in regards to staff not responding to resident’s call pendant in a timely manner. It was also learned that occasionally the alert was not responded; therefore, it is unclear if residents receive the support that residents needed. On 10/19/2023, it was learned that pthe state’s words, verbatim · CDSS document, Oct 24, 2023 · control 27-AS-20231010102244

Allegation investigated: Staff are not providing a resident with a copy of financial statements

On 10/19/2023 at 8:10 AM, Licensing Program Analyst (LPA) Pang Lee arrived unannounced to this facility to conduct a complaint visit. LPA met with administrator, Luis Olivas and explained the purpose of the visit. The purpose of this visit is to deliver complaint finding for the allegation above. The current census is 147. A brief interview was conducted with administrator, Luis Olivas. Allegation: Staff is not providing a resident with a copy of financial statements. It was alleged that the staff is not providing a resident with a copy of financial statements. This investigation consisted of records reviewed, interviews with staff, residents, and the resident responsible party. Throughout the course of the investigation, it was learned that resident 1 (R1)’s first and second invoice statement was sent to (R1) responsible party (RP), who then will forward the invoice statement to (R1). During the investigation, it was learned through (R1) that the facility may have misinterpreted (R1)the state’s words, verbatim · CDSS document, Oct 19, 2023 · control 27-AS-20230911162731

Allegation investigated: Personal Rights: Staff stole and fraudulently used residents credit cards. Reporting Requirements: Facility is not adhering to reporting requirements.

Licensing Program Analyst (LPA) Kevin Gould made an unannounced inspection to the Oakmont of East Sacramento on 9/22/23 at 2:15pm to conclude the investigation of the above allegations and to deliver the findings. LPA met with Administrator and together discussed the investigation details. Based on the interviews and statements obtained during the investigation process, the allegations have been corroborated. The facility has self reported four instances of credit card theft and unauthorized credit card use. LPA interviewed three of the victims and two of the resident's interviewed were able to confirm that their credit cards were stolen and used without prior authorization. The facility had reported the instances of theft to local police department who concluded their investigation and arrested a staff member S1 (see confidential names list, LIC 811 dated 9/22/23) and is being charged with 12 felony counts per Administrator. Report Continued on LIC 9099-C Substantiatedthe state’s words, verbatim · CDSS document, Sep 22, 2023 · control 27-AS-20230728113120

Allegation investigated: Licensee does not ensure the facility is in good repair.

On 09/05/2023 at 8:00 AM, Licensing Program Analyst (LPA) Avelina Martinez arrived at the facility unannounced to deliver complaint findings. LPA Martinez met with Luis Olivas during today’s visit and, explained the purpose of today’s visit. Throughout the course of this investigation, LPA Martinez conducted interviews and reviewed facility records. It was learned one of the facility's elevators was out of service on August 01, 2023. The facility contacted their contracted service operations repair company on August 02, 2023. In addition, the repair company inspected the elevator on August 02, 2023, and determined the elevator door motor was broken. A replacement part was order in a timely manner. However, the replacement part shipment was delayed. The elevator was repaired on August 11, 2023. Furthermore, during the time the elevator was out of order, the facility implemented meal tray service and transportation assistance for all resident. Continued... Unsubstantiatedthe state’s words, verbatim · CDSS document, Sep 5, 2023 · control 27-AS-20230804090806