Oakmont of East Sacramento

Allegation investigated: Physical Plant: Staff did not ensure there was a space ready/big enough for scheduled activity for residents

Licensing Program Analysts (LPA) Kevin Gould made an unannounced inspection to Oakmont of East Sacrament RCFE on 8/5/26 at 2:30pm to conclude the investigation of the above allegation and to deliver the findings. LPA Gould met with Assistant Executive Director, Shasta Mccune, and together discussed the investigation details. Based on the interviews conducted during the investigation process and statements obtained during the investigation process, LPA Gould was unable to corroborate the allegations. LPA conducted interviews with two staff members and five residents (see confidential name list LIC-811 dated 8/5/26). Staff interviewed denied the allegation. Staff interviewed both identified the relocation of exercises classes at the facility was for a one day conference and the ballroom where daily exercise takes places was moved to another designated fitness room located in the facility. This change was only for two days and both staff identified the activity space as having appropriate space for the number of attendees. LPA observed both activity spaces and observed ample room for the desired activity based on the number of attendees present. Report Continued on LIC 9099-C. Unsubstantiated Additionally, LPA conducted interview with five residents who provided statements of regularly attending fitness classes or other activities provided by the facility. All five residents interviewed provided statements to LPA that the fitness classes or other activities are conducted in a safe and healthful manner. All residents interviewed provided statements of having plentiful room to conduct exercises or preferred activities they attend. Although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. The Department has determined that the allegations of Physical Plant are unsubstantiated but if any additional information is received this complaint can be amended and the finding can be changed. There are no deficiencies is cited per California Code of Regulations, TITLE 22. Exit interview was conducted with facility staff. Appeal Rights were issued, and a copy of this report was left at the facility.the state’s words, verbatim · CDSS document, Aug 5, 2026 · control 27-AS-20260202121231

Allegation investigated: Staff do not ensure the court yard door is unlocked for residents

Licensing Program Analyst (LPA) Kevin Gould conducted an unannounced complaint inspection at Oakmont of East Sacramento RCFE on 2/25/26 to inform the licensee of complaint allegation mentioned above. During this investigation LPA Gould interviewed S1 (See confidential name list LIC-811 dated 2/25/26). S1 denied the allegation and provided statements to LPA that the courtyard is fully enclosed and there is no reason to lock the interior courtyard doors. LPA conducted a walk through around the facility and observed several doors unlocked leading to the courtyard. LPA did not observe any locked doors leading to the courtyard. LPA observed a short video showing the door was locked, upon investigation, the door was locked but it was a double door and the other door was not locked and was omitted from the video. LPA also observed an electronic door opening button that was active and opened the door in question. S1 states they cannot and would not turn off the door opening button. Report Continued on LIC 9099-C. Unsubstantiated Although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. The Department has determined that the allegation of physical plant is unsubstantiated but if any additional information is received this complaint can be amended and the finding can be changed. There are no deficiencies is cited per California Code of Regulations, TITLE 22. Exit interview was conducted with facility staff. Appeal Rights were issued, and a copy of this report was left at the facility.the state’s words, verbatim · CDSS document, Feb 25, 2026 · control 27-AS-20260218110431

Type of visit: Case Management - Incident

On 02/10/2026, Licensing Program Analyst (LPA) Pang Lee arrived unannounced to the facility to conduct a case management visit in regard to incident reports received. LPA Lee met with Executive Director (ED) Kathleen Gilbey and explained the purpose of the visit. The census is 151. On 08/18/2025, the Sacramento South Adult and Senior Care (ASC) Regional Office (RO) received a self-reported incident from Oakmont of East Sacramento involving Resident 1 (R1), who reportedly engaged in two separate sexual relationships with Resident 2 (R2) and Resident 3 (R3) while residing at the facility. During an interview, R2 denied knowing R1 and stated that the reported incidents never occurred. R2 further indicated that nothing inappropriate happened and denied being forced to participate in any activity against R2’s will. R3 did not respond to interview questions and was unresponsive during the interview. It was learned that R1 had moved out of the facility on 08/19/2025. A review of facility records indicates that staff were aware of R1’s inappropriate and sexualized behaviors and were actively addressing the concerns. Documentation shows that R1 was transported to Kaiser Emergency Room on multiple occasions for evaluation related to these behaviors. As a result, staff required R1’s family to arrange one-to-one supervision. Additionally, R1’s medications were adjusted in an effort to manage R1’s behaviors. Facility charting notes indicate that R1 began exhibiting concerning behaviors in June 2025. On 07/01/2025, the facility met with R1’s family and primary care physician to address the behaviors. On 07/29/2025, facility staff met with R1’s neurologist regarding the ongoing concerns. On 08/07/2025, the facility met with R1’s power of attorney and responsible party to further address R1’s behaviors. Charting notes also document multiple occasions when R1 was sent to the emergency room due to these behaviors. CONTINUED LIC 809-C Additionally, it was confirmed that the responsible parties for both R2 and R3 were informed of the situation, were aware of their respective interactions with R1, and expressed support and acceptance. The facility informed R1’s responsible party that R1 required continuous one-to-one supervision due to R1’s behaviors. Subsequently, R1’s responsible party elected to remove R1 from the facility. Per California Code of Regulations, Title 22, no deficiencies were observed during this visit. Exit interview was conducted and a copy of this report was provided.the state’s words, verbatim · CDSS document, Feb 10, 2026

Type of visit: Required - 1 Year

On 2/4/26 at 9:15am Licensing Program Analyst (LPA) Kevin Gould arrived at Oakmont of East Sacramento for the purpose of conducting a required 1 year annual inspection. LPA met with Administrator, Kathleen Gilbey and together conducted a tour of the facility. The facility is a three story facility consisting of Assisted Living and Memory Care. LPA and Administrator evaluated the physical plant to ensure the health and safety of the residents in care. Areas inspected are including but not limited to the kitchen, resident bedrooms; resident bathrooms, living and dining room and outdoor areas. LPA Gould also observed two movie theaters, fitness room, salon, massage room, several activity rooms and ballrooms. LPA observed the facility to be free of odor, clean and in good repair. LPA observed that all rooms are equipped with the required furniture and sufficient lighting throughout the facility. LPA measured the water temperature, temperature measured at 108 degrees F which meets the 105-120 degree Fahrenheit regulation. LPA observed sufficient seven day non-perishable and two day perishable food supplies. Fire extinguishers and smoke detectors are current and in compliance with fire safety. LPA notes the facility had the required carbon monoxide detectors. First aid kit was checked and is complete. LPA observed centrally stored medications secure from residents. LPA reviewed 8 resident files and 8 staff files. All files reviewed were complete and well organized. Report Continued on LIC 9099-C LPA Requested the following documents for facility file: LIC 308 Designation of Facility Responsibility, LIC 500 personnel report, Current Administrator Certificate and Client Roster. Per California Code of Regulations, Title 22 there were no deficiencies cited during today's inspection. An exit interview was conducted, and a copy of this report was left at the facility.the state’s words, verbatim · CDSS document, Feb 4, 2026

The state marks this report as 4 pages; the online copy we transcribed has 3. You can request the full file from the county licensing office.

Allegation investigated: Staff posted resident's picture on social media without consent

On 12/02/2025, Licensing Program Analyst (LPA) Pang Lee arrived unannounced to this facility to conduct a complaint visit. LPA met with Assistant Executive Director Shasta Mccune and Memory Care Director Kelli Hendrix and explained the purpose of the visit. The purpose of this visit is to deliver complaint finding for the above allegation. The current census is 153. A brief interview was conducted with Assistant Executive Director Mccune and Memory Care Director Hendrix. It was alleged that staff posted a resident’s picture on social media without consent. This investigation included a review of records and interviews with staff and a resident. During the investigation, it was learned that a facility staff member (S1) posted an Instagram story showing another staff member (S2) with Resident 1 (R1). Although S1 acknowledged posting the image, the resident’s face was covered with an emoji, and only the resident’s body from the neck down was visible. CONTINUED LIC 9099-C Unsubstantiated In addition, S1 referred to R1 only as “she” rather than by name. As a result, R1’s identity was not disclosed on social media. Furthermore, records and interviews confirmed that both staff members involved had received appropriate training on resident rights, HIPAA, confidentiality, and the facility’s team member handbook, which includes policies on social media and internet posting. Moreover, in an interview with 5 out of 5 facility staff who stated that both S1 and S2 were appropriately trained and are aware of policies and procedures. In an interview with R1 who stated “I don’t know” when asked if S1 asked R1 for permission to have their photo taken. In addition, it was learned that disciplinary measures will be taken, including the termination of (S1) and (S2). Based on these findings, the investigation determined that the preponderance of evidence standard was not met, therefore, the above allegation that staff posted a resident’s picture on social media without consent is found to be UNSUBSTANTIATED. An unsubstantiated finding means that while the allegation may have happened or is valid there is not a preponderance of the evidence to prove that the alleged violation occurred. An exit interview was conducted with Assistant Executive Director Mccune and Memory Care Director Hendrix, and a copy of this report was provided to the facility.the state’s words, verbatim · CDSS document, Dec 2, 2025 · control 27-AS-20251114155950

Type of visit: Case Management - Other

An unannounced case management visit was conducted by the Licensing Program Analysts (LPAs) Avelina Martinez and Pang Lee on November 25, 2025, at 11:46 AM. LPAs met with Kathleen Gilbey to explain the purpose of the visit. The purpose of the visit is to follow up on an incident report received on October 29, 2025. During today's visit, LPAs conducted interviews and followed up on the egress system. An exit interview was conducted, and a copy of this report was provided to the facility.the state’s words, verbatim · CDSS document, Nov 25, 2025

Type of visit: Case Management - Other

An unannounced case management visit was conducted by the Licensing Program Analyst (LPA) Avelina Martinez on November 10, 2025, at 11:46 AM. LPA Martinez met with Kelli Hendrix to explain the purpose of the visit. The purpose of the visit is to follow up on an incident report received on October 29, 2025. During today's visit, LPA Martinez conducted interviews and conducted a tour of the exterior of the building. At this time, R1 has a 1:1 caregiver and is being provided hourly status checks by facility staff. The exterior exit gate next to the dog park is non-operable a this time. The following documents were requested: R1's current needs and service plan, an updated facility sketch reflecting all egress exterior doors, an updated plan of operation to reflect the use of a secured perimeter at the Assisted Living building, R1's admission agreement, level of care point assessment fee breakdown, wander guard policy and procedures, and R1's safety plan for unauthorized absences. Staff agrees to email documents to LPA Martinez by November 17, 2025, by 5:00 PM. LPA Martinez will request a fire clearance for the egress exterior door. LPA Martinez will continue to follow up on R1'a safety plan, egress door installation, and fire clearance. There were no deficiencies at this inspection visit. An exit interview was conducted, and a copy of this report was provided to the facility.the state’s words, verbatim · CDSS document, Nov 10, 2025

Allegation investigated: Staff forced residents to attend an outing.

On 10/17/2025, Licensing Program Analyst (LPA) Cynthia Tamayo arrived unannounced to this facility to conduct a complaint visit. LPA met with receptionist and requested to meet with Facility Designated Administrator (FDA), Kathleen Gilbey and was informed they were in a meeting. Assistant Executive Director (AED) Flint Maranan was not present during this visit. LPA met with Activities director, Shantel Koehler (S1) shortly after explained the purpose of the visit. The purpose of this visit is to open and deliver a complaint finding for the above allegation. An interview was conducted with S1 and FDA. The current census is 149.LPA requested the following documents for review Personnel Report (LIC 500) and LIC 9020 Resident Roster, October activity calendar, October Activity attendance sheets. It was alleged Staff forced residents to attend an outing. LPA Tamayo interviewed nine (9) residents and six (6) staff. Continued on 809-C Unfounded LPA observed there are a variety of activities offered including lunch outings that take place about 1-2 times per week to different establishments. A flyer for the outing that took place on October 10 was posted prior to the activity date, it read “Join Oakmont East Sacramento on a lunch trip to Oakmont’s very own Flint Maranan’s new Sushi restaurant! Surki Sushi & Teriyaki Grill is a casual Japanese restaurant that brings bold flavors and fresh ingredients to the heart of West Sacramento. Sign up with Concierge". FDA stated AED's wife is an owner of a new restaurant, Suruki Sushi and it was the first and only time they have hosted an outing to this location; Based on record review and interviews it was learned that additional outings in the month of October include "University of Beer", "temple Coffee", "Fizz and Champaign Bubble Bar", "Jayna Gyro" as well as Apple Hill, Picinc at McKinley Park, Monet Exhibit, and Top Golf. S1 hosts a monthly meeting "Activity meeting" in which all residents and family members are welcome to collaborate and give input into activities offered, this meeting last took place in August and will resume November 2025. Family and residents are able to make activity suggestions to Activities Director at any time. Record review shows that two residents were in attendance to the outing that took place on October 10th, 2025. 9 out of 9 residents and 6 out of staff interviewed were not able to corroborate staff has ever forced or pressured residents to attend an outing. The Department has investigated the complaint alleging Staff forced residents to attend an outing. Based on the investigative interviews, record reviews and other supportive evidence, the complaint is determined to be unfounded, meaning that the allegation was false, could not have happened and/or is without a reasonable basis. There are no deficiencies cited per California Code Regulation, TITLE 22. Exit interview was conducted with the facility administrator. Appeal Rights were issued, and a copy of this report was left at the facility.the state’s words, verbatim · CDSS document, Oct 17, 2025 · control 27-AS-20251011140425

Allegation investigated: Staff does not give residents access to common area.

On 10/07/2025, Licensing Program Analyst (LPA) Pang Lee arrived unannounced to this facility to conduct a complaint visit. LPA met with Facility Designated Administrator (FDA), Kathleen Gilbey and Assistant Executive Director (AED) Flint Maranan and explained the purpose of the visit. The purpose of this visit is to open and deliver a complaint finding for the above allegation. The current census is 151. A brief interview was conducted with both FDA Gilbey and AED Maranan. During the investigation, it was learned that the facility holds a daily stand-up meeting every weekday at 9:30 AM in the facility library to review operations. On 10/01/2025, when staff 1 (S1) arrived at the library for the scheduled meeting, S1 observed Resident 1 (R1) and their privately hired companion (PHC) using the space to help calm R1 through breathing exercises. S1 approached R1 and the companion, informed them of the scheduled staff meeting, and suggested they move to the spa room, which is quieter and more suitable for their activity. CONTINUED LIC 9099-C Substantiated It was reported that the companion responded by stating, “I am surprised you are not allowing us to have it done here.” S1 explained that the library is regularly used by staff at 9:30 AM on weekdays for operational meetings. According to S1, the companion appeared displeased, but both the companion and R1 left the library to allow the staff to proceed with their meeting. Based on interviews conducted during the investigation, LPA Lee was able to corroborate the allegation. As a result, this allegation is SUBSTANTIATED. The finding that the complaint is substantiated means that the allegation is valid because the preponderance of the standard has been met. Deficiency cited on the LIC 9099-D, per Title 22 Regulations. An exit interview was conducted with (FDA), Gilbey and a copy of this LIC 9099, LIC 9099-D page and appeal rights provided to facility.the state’s words, verbatim · CDSS document, Oct 7, 2025 · control 27-AS-20251006105145

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87468.1(a)(2) · Plan of correction due date: Oct 13, 2025

87468.1(a)(2) 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... This requirement is not met as evidenced by: Based on interview a staff asked a resident and their privately hired companion who was in the library to move their breathing exercise to the spa area. This posed a potential risk to residents in care.the state’s words, verbatim · CDSS document, Oct 7, 2025

Plan of correction: Facility Designated Administrator (FDA), Kathleen Gilbey agrees to have their stand-up meeting held in the FDA’s office moving forward and not in the library. FDA and AED will review the regulation cited and provide LPA Lee with a statement of acknowledgment of understanding the regulation cited today. POC due 10/13/2025 end of day 5:00 PM.

Type of visit: Case Management - Incident

On September 5, 2025, LPA Pang Lee conducted an unannounced case management visit to Oakmont of East Sacramento. Upon arrival, LPA met with Executive Director (ED) Kathlee Gilbey and explained the purpose of the visit, which was to gather additional information and facility documentation related to a SOC 341 report dated August 18, 2025, and received by Community Care Licensing Division (CCLD) via fax on August 19, 2025. According to the SOC 341 report, a resident's wife observed Resident 1 (R1) engaging in sexually inappropriate behavior with another resident (R2) while seated on a couch in a common area. Additionally, it was reported that R1 has previously had inappropriate sexual interactions with multiple female residents at the facility. The ED and Memory Care Director Kelli Hendrix (MCD) reported that a safety plan has been implemented upon discovering of R1’s behavior to address the behavior of R1 with R1’s responsible party to ensure the well-being of R1 and other residents. During the visit, it was learned that R1 has moved out of the facility. LPA Lee collected the following documentation for further review and investigation: For Resident 1 (R1): · Admission Agreement CONTINUED LIC 809-C · LIC 624 – Incident Reports · Charting Notes · Medication List For Residents 2 (R2) and 3 (R3): · LIC 602 – Physician’s Report · LIC 625 – Needs and Services Plan · Charting Notes · LIC 624 – Incident Reports · Admission Agreement Per California Code of Regulations, Title 22, no deficiencies were cited. Exit interview conducted and a copy of this report was left at the facility.the state’s words, verbatim · CDSS document, Sep 5, 2025

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 Unsubstantiated Additionally, LPA Lee interviewed 6 out of 6 family members and friends of residents. None expressed concerns regarding incontinence care, and all reported that their loved ones are regularly changed by care staff. They also stated that they have not observed their loved ones in soiled or unclean incontinence briefs. Interviews were also conducted with 5 out of 5 residents, all of whom stated that their incontinence care needs are being met by the facility staff and expressed no concerns. During a facility observation on 07/30/2025, no signs of incontinence odor were detected. Based on interviews and statements conducted during the investigation process as well as direct observations, LPA Lee was unable to corroborate the allegation that staff do not ensure residents incontinent care are being met. It was alleged that staff do not allow residents to eat their meals in a comfortable manner. The investigation included interviews with staff, residents, responsible parties, and direct observations. LPA Lee interviewed all five facility staff members. Each staff member denied the allegation and reported that lunch is typically served between 11:30 AM and 1:00 PM. LPA Lee also interviewed six out of six family members and friends of residents. None of them expressed concerns about residents being unable to eat their meals comfortably. They reported regularly sitting with their loved ones during mealtimes and stated that meals are not rushed. They felt residents are given sufficient time to eat and shared that facility staff are often seen sitting with and assisting residents who may need more assistance with feeding. Additionally, interviews were conducted with all five out of five residents. All residents reported no concerns regarding mealtimes. On 7/30/2025, at approximately 11:15 AM, LPA Lee conducted a tour of the memory care unit. During this observation, care staff were seen assisting residents in the dining area. Lunch service began at around 11:20 AM and continued until approximately 1:00 PM. Throughout the observation, LPA Lee observed a calm and unhurried dining environment, where residents were given adequate time to eat. Five care staff were observed assisting residents with their meals, while two med-techs distributed medications. Approximately 29 residents were present in the dining room during this time. Resident 1 (R1) was observed receiving assistance with their meal but later declined further help from staff. Based on interviews and statements conducted during the investigation process as well as direct observations, LPA Lee was unable to corroborate the allegation that staff do not allow residents to eat their meals in a comfortable manner. It was alleged that staff do not ensure residents are treated with dignity and respect regarding their health conditions. CONTINUED LIC 9099-C The investigation included interviews with facility staff, residents, responsible parties, and direct observations. LPA Lee interviewed all five facility staff members. Each staff member denied the allegation, stating that residents are treated with dignity and respect. LPA Lee also interviewed six out of six family members and friends of residents. None expressed concerns about how staff treat residents. One friend of a resident stated, “They are loved here.” Another shared that they have no concerns about the care their loved one receives. A third individual noted they have visited their loved ones’ room and observed staff providing care in a kind and respectful manner. All family members and friends of residents stated that they have not witnessed any incidents of staff treating residents without dignity or respect, especially regarding residents’ health conditions. Additionally, five out of five residents interviewed reported no concerns about how they are treated by staff in relation to their health conditions. Based on interviews and statements conducted during the investigation process as well as direct observations, LPA Lee was unable to corroborate the allegation that staff do not allow residents to eat their meals in a comfortable manner. The investigation revealed the preponderance of evidence standards have not been met; therefore, the above allegations are found to be UNSUBSTANTIATED. A finding that the complaint allegations are UNSUBSTANTIATED means that although the allegations may have happened or are valid, there is not a preponderance of the evidence to prove that the alleged violation(s)occurred. Per California Code of Regulations (CCRs) - Title 22, Division 6, Chapter 6, no deficiencies were cited. A copy of this report was provided at the end of the visit.the state’s words, verbatim · CDSS document, Aug 22, 2025 · control 27-AS-20250728104736

Type of visit: Required - 1 Year

On 04/22/2025 at 8:30am, Licensing Program Analyst (LPA) Pang Lee and Shakaricka Hughes arrived at the facility to conduct an unannounced annual inspection. LPA Lee and Hughes met with Kathleen Gilbey explained the purpose of the visit. The facility designated administrator was present in the facility. The current census is 146 and facility staff is 112 LPA's inspected the physical plant to ensure the health and safety of the residents in care. Areas inspected are including but not limited to the kitchen, resident bedrooms; resident bathrooms, living and dining room and outdoor areas. LPA's also toured both the assistant living and memory care. LPA's observed activity rooms, wellness cove, private dining, massage room, and media ballroom. LPA's observed sufficient lighting throughout the facility. LPA's observed the facility to be clean and in good repair. LPA observed residents’ rooms and they are equipped with the required furniture. LPA's observed resident room 109 had a very strong urine odor. It was learned R1 moved to the facility of 2/1/2025 and it was learned that resident has a change in condition. Based on record review, resident has proper documentation in place. During today's visit maintenance shampooed resident's carpet. Resident will relocate to another room temporarily. There are no bodies of water present. LPA's toured the kitchen and observed sufficient seven-day non-perishable and two-day perishable food supplies. Hot water temperature was measured at 109.1 degrees Fahrenheit in resident bathroom sink, which is within the required regulation of 105 to 120 degrees Fahrenheit. Grab bars and non-slip mat were observed to be stable and in good repair at this time. Smoke and carbon monoxide detectors are in compliance with fire safety. Continuation 809-C The fire extinguisher is located in the hallways of each floor and was last serviced on 04/16/2025. LPA's observed the facility has a has a public telephone in the staff offices and the facility has the required posters posted. Facility thermostat was 73 degrees Fahrenheit. LPA's observed toxins located in the kitchen area and kept locked and inaccessible to residents. LPA's observed sharp knives in the kitchen and inaccessible to residents. LPA's checked medication storage and found medication to be locked away and inaccessible to residents. LPA reviewed 5 residents medications and the medication administration record (MAR) was complete. The first aid kit was checked and contained the required components. LPA's requested resident and staff files for review. LPA's reviewed 10 out of 10 resident files and it was complete.LPA's reviewed staff criminal record clearances, and a review of staff records indicates that all facility staff or other individuals who require caregiver background checks are fingerprint cleared. The following documents will be email to LPA by end of day 5:00 PM: (1) LIC 308 Designation of Administrative Responsibility (2) Copy of Administrator Certificate (3) LIC 610 Current Emergency Disaster Plan (4) Proof of Current Liability Insurance (5) LIC 500 Current Personnel Report (6) LIC 309 Administrator Organization As a result of this annual visit, the facility is in compliance with Title 22 Regulation, An exit interview was conducted with Kathleen Gilbey and a copy of these LIC 809, LIC 809-C, LIC 9102 reports, and Appeals rights were provided to the facility.the state’s words, verbatim · CDSS document, Apr 22, 2025

The state marks this report as 4 pages; the online copy we transcribed has 3. You can request the full file from the county licensing office.

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 apartment and across the hall. Unsubstantiated It was stated that after inspection there was no evidence to show that there were presence of bed bugs in those apartments other than the affected unit. In addition, the facility ensured to bag up any clothing and went through high heat washing and drying as directed by Eco Lab. About 3 weeks later, the facility stated that the apartment across the hall had bed bugs. Facility management decided that it was best to call in another company to inspect the apartment. That company then conducted a heat treatment and inspected the apartments next to the affected apartment and did not have indications of bed bugs present. A review of the facility records of invoice records of both Eco Lab and Premier Pentacle that show that the facility went through bed bug treatment immediately after the notification of bed bugs. In addition, LPAs observed bed bug canine servicing that was conducted during the visit conducted on 10/30/2024. Based on the information gathered, it is unclear if the facility did not keep the facility free from bug infestation. Allegation: Staff did not ensure a resident had sufficient clothing It was alleged that staff did not ensure a resident had sufficient clothing. During the course of this investigation, LPA reviewed facility records and conducted interviews. Based on interviews conducted, it was learned that the facility hired a second bed bug company Premier Pentacle who advised that all belongings were to be left in the apartment unit to ensure that all items were treated with high heat. As a response, the facility moved two residents over to another unit and contacted their responsible parties to inform them that they would not have their belongings for several days. However, due to unforeseen circumstances, the responsible parties were unable to gather clothing or hygiene items for these residents. In response, the facility went out to local department stores and bought items such as pillows, t-shirts, pants and hygiene items. A review of the facility invoices and copies of these receipts were reviewed and confirmed that the facility had bought these items for the residents affected by the bed bugs. In addition, an interview with 2 residents confirmed that they had clothing at the time of transfer. Based on the information gathered, it is unclear if the staff did not ensure a resident had sufficient clothing. As a result of this investigation, this Department found the allegations to be UNSUBSTANTIATED. A complaint allegation finding of Unsubstantiated meant that although the allegations may have happened or was valid, there was not a preponderance of the evidence to prove that the alleged violation occurred. An exit interview was conducted and a copy of this report was provided to the facility at the end of this visit.the 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 that residents needed. Continued LIC 9099-C Substantiated It was also learned from Vice President of Operation, Terry Ervin that the facility response time is between 15 minutes or less. The documents revealed that 7 out of 8 residents SMART care log were not responded within 15 minutes or less minutes per Vice President of Operation, Terry. In addition multiple SMART care logs indicated that staff did not respond to residents until 30 minutes later. As a result, this allegation is SUBSTANTIATED. A finding that the complaint is substantiated means that the allegations are valid because the preponderance of the standard has been met. Deficiencies cited on the LIC 9099-D, per Title 22 Regulations. An exit interview was conducted with administrator and a copy of this LIC 9099, LIC 9099-D page and appeal rights provided to facility. It was also learned that (R1) needed assistance with staff helping (R1) carry the oxygen tank to put on (R1)’s new motorized wheelchair. Based on (R1)’s Physician Report (R1) is able to administer his/her own oxygen. Moreover, (R1)’s Resident’s Assessment dated on 04/30/2024, (R1) uses continuous oxygen and requires staff monitoring and assistance of an appropriately skilled professional. (R1)’s Individualized Service Plan (ISP) also states that (R1) needs assistance with (R1)’s portable oxygen tank and placing on (R1)’s electric scooter, every morning. (R1) also needs to have oxygen tank checked each evening in preparedness for the next day. Based on records reviewed, It was learned that on 05/18/2024 (R1)’s oxygen tank was check during the morning, noon and evening. The investigation revealed the preponderance of evidence standards have not been met; therefore, the above allegations are found to be UNSUBSTANTIATED. A finding that the complaint allegations are UNSUBSTANTIATED means that although the allegations may have happened or are valid, there is not a preponderance of the evidence to prove that the alleged violation(s)occurred.the state’s words, verbatim · CDSS document, Jul 23, 2024 · control 27-AS-20240520110159

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87303(i)(1)(B) · Plan of correction due date: Aug 2, 2024

87303(i)(1)(B) Maintenance and Operation (i) Facilities shall have signal systems which shall meet the following criteria: (1) All facilities licensed for 16 or more and all residential facilities having separate floors or buildings shall have a signal system which shall: (B) Transmit a visual and/or auditory signal to a central staffed location or produce an auditory signal at the living unit loud enough to summon staff. This requirement was not met as evidence by: Based on 7 out 8 resident SMART care log it was learned that residents alert call was not responded to and that occasionally calls took over 15 minutes to respond, which poses a potential health, safety, or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Jul 23, 2024

Plan of correction: The administrator will review SMART care log and conduct an audit and ensure to conduct additional training with facility staff; furthermore, ongoing training will also be conducted. Administrator also agrees to submit proof of training and the training materials used along with staff sign in sheet. Administrator will also review regulations being cited today and write a statement of acknowledging that administrator along with facility staff are aware of the regulation being cited today. POC will be email to LPA Lee at pang.lee@dss.ca.gov by POC date 08/02/2024 by end of day 5:00 PM.

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 assessments conducted on 07/06/2023, 07/21/2023, 12/09/2023 and 04/01/2024 did not have any changes to personal care services. Unsubstantiated All assessments conducted do not have showering or bathing as care provided to R1. A review with R1's physician report states that R1 is able to bathe, dress, groom, and take care of their own toileting needs. An interview with 9 residents were conducted. 1 out 9 residents state that their significant other needed assistance with their showers but did not receive any help when pressing their call button. 8 out 9 residents state that they receive assistance with their showers and do not have any issues at this time. An interview with 5 staff members were conducted. 1 out 5 staff members do not provide direct care needs. 4 out 5 staff members deny not providing R1 or any other resident with assistance with their shower. 1 out 5 staff members state that based on their knowledge the facility did not provide R1 with any assistance with bathing because R1 would deny showers or would not need any help. Based on the information gathered, it is unclear if the facility did not provide the resident with showering needs. Allegation: Staff did not ensure the residents blood glucose testing equipment was working properly It was alleged that staff did not ensure that the resident's blood glucose testing equipment was working properly. During the course of this investigation, this LPA reviewed facility records and conducted staff and resident interviews. Based on interviews conducted it was found that on 04/23/2024, R1 was sent to the hospital due to her high blood glucose levels. R1 admitted that they were unable to read their glucose levels because of their monitor being broken. R1's family member was able to purchase a new monitor, however, was not able to obtain it due to the purchase being delayed. A review R1's assessment and care plan did not have any care needs provided by the facility for diabetic monitoring. In addition, R1's physician report states that this resident is on a special diabetic diet however, is able to manage and administer their own medication. An interview with with 5 staff members were conducted. 1 out 5 staff members do not provide direct care needs. 4 out 5 staff members state that they did not provide this resident with diabetic care and that the resident handled all their medication and diabetic needs. Based on the information gathered, it is unclear if the facility did not ensure that the residents blood glucose testing equipment was working properly. Allegation: Staff did not ensure residents medication was reordered timely causing the resident to miss medication It was alleged that staff did not ensure residents medication was reordered timely causing the resident to miss medication. During the course of this investigation, this LPA reviewed facility records and conducted interviews. Based on interviews conducted it was learned that on 04/23/2024, R1 was sent to the hospital due to not taking their diabetic medication. An interview with 4 staff members were conducted. 4 out 4 staff members state that R1 was in charge of their medication based on their assessments and the physicians report obtained during admission. 4 out 5 staff member state that this resident was very independent and had denied help for maintaining their diabetic medication. A review of the residents personal care services state that this resident did not have any care needs from the facility regarding medication and notes state that the resident is able to self-manage medication and self medication assessment was completed by the facility. It was agreed that the resident was to provide the facility with a copy of their signed physician medication orders for emergencies. A review of the resident's physician report confirmed that this resident was able to administer, store, and perform their own glucose testing. Based on the information gathered, it is unclear that the staff did not ensure residents medication was reordered timely causing the resident to miss medication. As a result of this investigation, this Department found the allegations to be UNSUBSTANTIATED. A complaint allegation finding of Unsubstantiated meant that although the allegations may have happened or was valid, there was not a preponderance of the evidence to prove that the alleged violation occurred. An exit interview was conducted and a copy of this report was provided to the facility at the end of this visit.the 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 members were conducted. Unsubstantiated 5 out 5 staff members deny witnessing any residents speaking inappropriately with other residents. 5 out 5 staff members deny that they have spoken inappropriately to any residents. 5 out 5 staff members state that they would notify management of any issues based on the house rules. A review of the facilities staff house rules states that disruptive or abusive behavior by employees, residents, and resident's families or guests are not acceptable or permitted. 1 out 5 staff members stated that they would take all allegations of inappropriate comments seriously and would provide corrective actions in place to help mitigate and prevent any issues for the future. Based on the information gathered above it is unclear if the facility did not prevent a resident from making any inappropriate comments to other residents. As a result of this investigation, this Department found the allegations to be UNSUBSTANTIATED. A complaint allegation finding of Unsubstantiated meant that although the allegations may have happened or was valid, there was not a preponderance of the evidence to prove that the alleged violation occurred. An exit interview was conducted and a copy of this report was provided to the facility at the end of this visit.the 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 facility staff threw (R1)’s glasses away without informing (R1) and (R1)’s Power of Attorney (POA). Continued LIC 9099-C Unsubstantiated THIS IS AN AMENDED VERSION OF THE ORIGINAL REPORT DATED ON 07/23/2024. It is unclear how (R1)’s glasses were broken based on interviews. It was also learned that (R1)’s hearing aid was lost at the hospital when (R1) was admitted to the hospital. It is unclear to who lost (R1)’s hearing aid. On 04/26/2024 it was learned that the facility gave (R1) a reimbursement of $400 for (R1)’s glasses. The investigation revealed the preponderance of evidence standards have not been met; therefore, the above allegations are found to be UNSUBSTANTIATED. A finding that the complaint allegation is UNSUBSTANTIATED means that although the allegations may have happened or are valid, there is not a preponderance of the evidence to prove that the alleged violation(s)occurred. Moreover, (R1)’s LIC 602 Physician’s Report also indicate that (R1) is able to feed herself/himself. Based on (R1) charting notes, it was also learned that (R1) comes out to the dining room to eat her/his meal. The investigation revealed the preponderance of evidence standards have not been met; therefore, the above allegations are found to be UNSUBSTANTIATED. A finding that the complaint allegations are UNSUBSTANTIATED means that although the allegations may have happened or are valid, there is not a preponderance of the evidence to prove that the alleged violation(s)occurred.the state’s words, verbatim · CDSS document, Jul 23, 2024 · control 27-AS-20240419093805

Type of visit: Case Management - Incident

On 07/23/2024, Licensing Program Analysts (LPAs) Arielle Pascua and Pang Lee arrived unannounced to conduct a case management visit. LPAs met with Facility Designated Administrator (FDA), Kathleen Gilbey and explained the purpose of the visit. The purpose of this visit was to follow up on an incident report received by the department on 06/29/2024. On 06/23/2024, the department received an LIC 624 incident report that occurred on 06/23/2024 regarding resident 1 (R1). LPA reviewed the incident report, and it was learned that on 06/23/2024, during an internal community medication audit, it was noted that (R1)’s Megestrol Acetate 40 mg with directions of take 2 tablets by mouth 2 times daily for 3 weeks was not given to resident from 06/03/2024 to 06/06/2024, 06/12/2024 to 06/20/2024 for a total of 12 days. Furthermore, the incident report dated on 06/29/2024 states that R1 was diagnosed by a home health nurse that they have an unstageable wound on 06/20/2024 at 5:30pm and sent to UC Davis hospital for further evaluation on 06/21/2024. Based on record review, this incident report was faxed to the department on 06/29/2024, however the incident occurred on 06/20/2024 and 06/21/2024. As a result, the facility did not follow the reporting requirements. LPA obtained facility records. Due to insufficient time to review documentation and conduct interviews the department will come at a later date to follow up on the incident reported on 06/29/2024. The following deficiencies were observed and cited from the California Code of Regulations, Title 22, and California Health and Safety Code. The deficiencies can be found on the 809-D page. An exit was interview conducted, and a copy of the 809 report, 809-D page, and appeal rights were given to the facility.the state’s words, verbatim · CDSS document, Jul 23, 2024

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87211(a)(1) · Plan of correction due date: Aug 23, 2024

(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 of any of the events specified in (A) through (D) below. This report shall include the resident's name, age, sex and date of admission; date and nature of event; attending physician's name, findings, and treatment, if any; and disposition of the case. This is not met as evidenced by: Based on record review and interview the facility did not report R1's unstageable wound within 7 days of occurence. The incident occured on 06/20/2024 and 06/21/2024 and the facility did not provide the incident report to the department until 06/29/2024. This poses a potential health, safety, and personal rights risks to persons in care.the state’s words, verbatim · CDSS document, Jul 23, 2024

Plan of correction: Licensee shall provide a statement of correction and acknowledgement, along with proof of staff training for no less than (1) hour in duration, for the cited section will be completed and submitted to the LPA's email at arielle.pascua@dss.ca.gov by the due date od 08/23/2024 COB at 5:00pm. Information submitted must include attendees, trainers, and information discussed.

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(a)(4) · Plan of correction due date: Jul 24, 2024

87465 Incidental Medical and Dental Care (a) A plan for incidental medical and dental care shall be developed by each facility. The plan shall encourage routine medical and dental care and provide for assistance in obtaining such care, by compliance with the following: (4) The licensee shall assist residents with self-administered medications as needed. This was not met as evidenced by: Based on record review and interview the Licensee did not ensure that (R1) received (R1) medications as prescribed by (R1)’s physician’s order. The facility did not provide the residents medication prescribed by the doctor from 06/03/2024 to 06/06/2024 and again from 06/12/2024-06/20/2024. This poses an immediate health, safety, and personal rigths risks to persons in care.the state’s words, verbatim · CDSS document, Jul 23, 2024

Plan of correction: Licensee shall provide a statement of correction and acknowledgement, along with proof of staff training for no less than (1) hour in duration, for the cited section will be completed and submitted to the LPA's email at arielle.pascua@dss.ca.gov by the due date of 08/24/2024 COB at 5:00pm. Information submitted must include attendees, trainers, and information discussed.

Type of visit: Required - 1 Year

On 04/24/2024 at 8:28 AM, Licensing Program Analyst (LPA) Pang Lee arrived at the facility to conduct an unannounced annual inspection. LPA Lee met with administrator Kathleen Gilbey and explained the purpose of the visit. Administrator Certificate # 6059719740 expires on 05/19/2025. The current census is 138. LPA Lee and Marketing Director Janae Fernandez inspected the physical plant to ensure the health and safety of the residents in care. Areas inspected are including but not limited to the kitchen, resident bedrooms; resident bathrooms, living and dining room and outdoor areas. LPA Lee and Marketing Director also toured both the assistant living and memory care. LPA Lee observed two movie theaters, activity room, wellness cove, bar and lounge, private dining, fitness room, salon, massage room, activity rooms, wine cellar and media ballroom. LPA Lee observed sufficient lighting throughout the facility. LPA observed the facility to be clean and in good repair. LPA observed 10 residents’ rooms and they are equipped with the required furniture. LPA Lee and Marketing Director observed resident room 333 had a very strong urine odor. There are no bodies of water present. LPA measured the water temperature, temperature measured at 113.1 degrees F which meets the 105–120-degree Fahrenheit regulation. LPA observed sufficient seven-day non-perishable and two-day perishable food supplies. LPA Lee toured the kitchen and observed sufficient seven-day non-perishable and two-day perishable food supplies. Grab bars awere observed to be stable and in good repair at this time. Continued LIC 809-C Smoke and carbon monoxide detectors are in compliance with fire safety. Multiple fire extinguisher is located throughout the building in both assistant living and memory care building and was last serviced on 04/12/2024. Facility thermostat observed at 72 degrees Fahrenheit. LPA Lee observed toxins kept locked and inaccessible to residents. LPA Lee checked medication storage and found medication to be locked away and inaccessible to residents. LPA reviewed and compared 3 medication administration record (MAR) along with residents’ medications and it was complete. The first aid kit was checked and contained all the required components. LPA Lee checked and tested 5 residents pendant and it was observed that facility staff came to check on those 5 residents under 5 minutes. LPA Lee inspected the two elevator in the building and it is in good repair and is current and will expire on 08/23/2024. LPA Lee also inspected the exhaust hood and is in good repair. Last service date was on 02/15/2024 and an upcoming service date is scheduled for 06/2024. LPA Lee requested residents and staff files for review. LPA Lee reviewed 6 resident files and 5 staff files, and they were complete and organized. The following documents were given to LPA during today's visit. (1) LIC 308 Designation of Administrative Responsibility (2) LIC 610 Emergency Disaster Plan (3) Proof of Current Liability Insurance (4) Current LIC 500 Per California Code of Regulations, Title 22 there were no deficiencies cited during today's inspection. An exit interview was conducted, and a copy of this report was left at the facility.the state’s words, verbatim · CDSS document, Apr 24, 2024

The state marks this report as 3 pages; the online copy we transcribed has 2. You can request the full file from the county licensing office.

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 address R1's falls prior to most recent fall. Substantiated Interviews with staff including S3, S1, S5 and S7 revealed consistent statements of R1's decline in her ability to be stable and walk. S1, S5 and S7 detailed that R1 had three to four falls that occurred within the last six months of R1 living at the facility. S3, S1, S5 and S7 denied knowing about a fall prevention plan for R1. All of the staff agreed that the alert pendants were not reliable and do not always work. Additionally, regarding reporting requirements, A2 and A1 both provided statements to the department they were not contacted regarding R1's latest fall and hospitalization. These statements have been corroborated by R2 who provided statements that A2 was not aware of R1's fall and hospitalization or absence from the facility. Staff interviews were unable to corroborate a staff actually contacted an emergency contact and the facility was unable to provide any evidence of contact with emergency contacts. The Department has determined, based on the preponderance of the evidence obtained during this investigation, that the allegation of Neglect/Lack of Supervision, Reporting requirements and Other is substantiated. The following deficiencies are cited per California Code of Regulations, TITLE 22. Due to the identified violation resulting in a resident injury an immediate civil penalty is issued and the department will evaluate the circumstances of the violation for additional civil penalties. Exit interview was conducted with facility staff. Appeal Rights were issued, and a copy of this report was left at the facility.the state’s words, verbatim · CDSS document, Mar 20, 2024 · control 27-AS-20230921115438

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(a)(1) · Plan of correction due date: Mar 21, 2024

Incidental Medical and Dental Care: The licensee shall arrange, or assist in arranging, for medical and dental care appropriate to the conditions and needs of residents. This requirement was not met as evidenced by staff statements that they were aware of R1's decline in mobility but did not have a fall prevention plan in placement to address recurring falls which resulted in additional falls where R1 sustained a fracture which required hospitalization which poses an immediate health, safety and personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Mar 20, 2024

Plan of correction: Facility will submit an updated fall risk/prevention plan to the facility for approval and when approved will become part of the facility plan of operation. facility will also conduct training on communication, implementation and oversight of fall risk program by the POC due date 3/21/24.

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87468.1(a)(8) · Plan of correction due date: Mar 21, 2024

Personal Rights of Residents in All Facilities: To have their representatives regularly informed by the licensee of activities related to care or services, including ongoing evaluations, as appropriate to their needs. this requirement was not met as evidenced by statements from A1, A2 and R2 who corroborated statements that authorized representatives were not notified by facility staff of R1's fall and subsequent hospitalization which poses an immediate health, safety and personal rights risk for residents in care.the state’s words, verbatim · CDSS document, Mar 20, 2024

Plan of correction: Facility will provide and updated written plan of correction identifying the policies and procedures for notifying authorized representatives of incidents at the facility and will conduct appropriate training for staff to ensure reporting requirements are met.

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87303(i)(1)(A) · Plan of correction due date: Mar 21, 2024

Maintenance and Operation: Facilities shall have signal systems which shall meet the following criteria: Operate from each resident's living unit. This requirement was not met as evidenced by statements obtained from A1, A2, S1, S5, S3, and S7 that state they do not believe the call system operates properly and there are times where they are not notified of an alert from a resident's room and documented concerns of call system not working as designed which poses an immediate health safety and personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Mar 20, 2024

Plan of correction: Facility will submit a written plan of correction indicating the steps the facility takes to ensure regular testing of resident pendents and staff pagers to ensure they are operating as intended and staff receive notifications for assistance.

Type of visit: Case Management - Other

on 3/20/24 at 11:00am Licensing Program Analysts (LPA) conducted an unannounced case management inspection to address concerns discovered during an unrelated complaint investigation. LPA conducted and interview with S1 and R1. LPA conducted file review for R1. Due to time constraints the case management will be continued on a later date. There are no deficiencies cited per California Code of Regulations, TITLE 22. Exit interview was conducted with facility staff and a copy of this report was left at the facility.the state’s words, verbatim · CDSS document, Mar 20, 2024

Type of visit: Case Management - Other

On 11/16/2023 at 12:30 PM, Licensing Program Analyst (LPA) Pang Lee arrived at the facility unannounced to conduct a case management visit. LPA Lee met with administrator, Luis Olivas and explained the purpose of the visit. The census is 147. The purpose of today’s visit is in response to concerns that was brought to the department attention on 10/30/2023. The concerns was addressed during family council on 09/09/2023 and 10/10/2023. Family council has submitted in writing concerns and recommendations to facility. It was learned that the administrator, Luis Olivas did not ensure responses are in writing regarding action or in action to address these concerns to the family council within the 14 calendar days. A family council was held on 09/09/2023 and no written response was provided until 09/28/2023. Furthermore a family council that was held on 10/10/2023 no written response was provided as of today. Per administrator, Luis, a verbal response was provided on 11/14/2023, during the November family council meeting. It was also learned that phone calls and emails were sent to both administrator, Luis Olivas and Vice President of Operations Terry Ervin. The following deficiencies were observed and cited form California Code of Regulations, Title 22, and California Health and Safety Code. An exit interview was conducted, and a copy of this LIC 809 report, LIC 809-D and appeal rights were given to administrator, Luis Olivas.the state’s words, verbatim · CDSS document, Nov 16, 2023

From the deficiency page — Deficiency type: Type B · Section cited: CCR 1569.158(f) · Plan of correction due date: Nov 30, 2023

§1569.158(f) Family councils f a family council submits written concerns or recommendations, the facility shall respond in writing regarding any action or inaction taken in response to the concerns or recommendations within 14 calendar days.the state’s words, verbatim · CDSS document, Nov 16, 2023

Plan of correction: Administrator agrees to provide written response to concerns addressed during family councils meetings within 14 calendar days. Administrator also agrees to review regulation being cited today and write a statement of acknowledging that administrator is aware of the regulation being cited today. POC will be email to LPA Lee at pang.lee@dss.ca.gov by POC date 11/30/2023 by end of day 5:00 PM.

Type of visit: POC

Licensing Program Analyst (LPA) Pang Lee arrived at the facility on 11/16/2023 at 12:30 PM to conduct an unannounced Plan of Correction (POC) visit. LPA Lee met with administrator, Luis Olivas and explained the purpose of the visit. The purpose of this visit is to follow-up on prior deficiency and plans of correction that were due on 11/07/2023 from a complaint investigation which was conducted on 10/24/2023. The census is 147. As of the dated of this visit, 11/16/2023 at 12:30 PM, the department has not received any forms and documents from the administrator to support the plan of correction has been completed by the facility. Civil Penalties were assessed on today’s date for failure to correct 87303(i)(1)(B). The Facility was informed that the civil penalty will continue to accrue $100 per day per violation until the deficiency is corrected. However, during today's visit at 2:30 PM, administrator, Luis Olivas provided LPA Lee POC documents of training materials and staff sign in sheet for the Personal Health Button Report (PHBR) training. Administrator also provided statement of acknowledgement that administrator is aware of the regulation that was cited on 10/24/2023 and two audit (PHBR) logs. Based upon this inspection and interview, the LPA observed the following: I. The deficiency cited under Title 22 Regulation 87303(i)(1)(B) has been cleared. The licensee did not complied with the terms of the POC by POC due date 11/07/2023; however, during today's POC visit, administrator, Luis Olivas provided POC documents to LPA Lee. A POC letter was generated and provided to the facility. An exit interview was conducted and a copy of this LIC 809 report, and civil penalties was provided to administrator, Luis at the end of this visit.the state’s words, verbatim · CDSS document, Nov 16, 2023

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 per a family member request a meeting was held on 10/19/2023 at 12:30 PM, in regards to staff not responding and attending to residents call pendant. Continued LIC 9099-C Substantiated During this meeting it was learned that VP of Operations Terry Ervin acknowledge that the facility can do better in responding to resident calls. It was also learned from administrator, Luis Olivas and VP of Operation, Terry Ervin stated that the facility response time is between 15 minutes or less. LPA Lee requested and reviewed 10 residents Personal Health Button Report (PHBR). The documents revealed that 3 residents (PHBR) were not responded within 15 minutes or less minutes per administrator, Luis and VP of Operation, Terry. Furthermore, the documents also revealed that 7 residents (PHBR) stated that residents’ calls were ever respond to. As a result, this allegation is SUBSTANTIATED. A finding that the complaint is substantiated means that the allegations are valid because the preponderance of the standard has been met. Deficiencies cited on the LIC 9099-D, per Title 22 Regulations. An exit interview was conducted with administrator and a copy of this LIC 9099, LIC 9099-D page and appeal rights provided to facility.the state’s words, verbatim · CDSS document, Oct 24, 2023 · control 27-AS-20231010102244

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87303(i)(1)(B) · Plan of correction due date: Nov 7, 2023

87303(i)(1)(B) Maintenance and Operation (i) Facilities shall have signal systems which shall meet the following criteria: (1) All facilities licensed for 16 or more and all residential facilities having separate floors or buildings shall have a signal system which shall: (B) Transmit a visual and/or auditory signal to a central staffed location or produce an auditory signal at the living unit loud enough to summon staff. This requirement was not met as evidence by: Based on LPA Lee investigation 7 out of 10 residents has a concern in regards to staff not responding to resident’s call pendant in a timely manner. LPA Lee requested and reviewed 10 residents Personal Health Button Report (PHBR). The documents revealed that 3 residents (PHBR) were not responded within 15 minutes or less minutes per administrator, Luis and VIP of Operation, Terry. Furthermore, the documents also revealed that 7 residents (PHBR) stated that residents’ calls were ever respond to, which poses a potential health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Oct 24, 2023

Plan of correction: Effective immediately the administrator will start reviewing Personal Health Button Report (PHBR) and conduct an audit and ensure to conduct additional training with facility staff; furthermore, ongoing training will also be conducted. Administrator also agrees to submit proof of training and the training materials used along with staff sign in sheet. Administrator will also review regulations being cited today and write a statement of acknowledging that administrator along with facility staff are aware of the regulation being cited today. POC will be email to LPA Lee at pang.lee@dss.ca.gov by POC date 11/07/2023 by end of day 5:00 PM.

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) when (R1) told the facility that (R1) wants (R1) reporting party (RP) to also receive (R1) invoice statement. Continued LIC 9099-C Unsubstantiated It was learned that (R1) was provided an account summary using a login portal. However, per healthy and safety code section 1569.884(b) (R1) is not receiving a monthly statement itemizing all separate charges incurred by the resident. It was also learned that (R1) request guest meal receipts to cross reference to (R1) invoice statement to itemized (R1) guest meal charges. Moreover, it was also learned that on 07/15/2023 (R1) was charged $15.00 for another resident guest meal and then the facility reversed the charges on 08/09/2023. As a result, this allegation is SUBSTANTIATED. A finding that the complaint is substantiated means that the allegations are valid because the preponderance of the standard has been met. Deficiencies cited on the LIC 9099-D, per Title 22 Regulations. An exit interview was conducted with and a copy of this LIC 9099, LIC 9099-D page and appeal rights provided to facility. It was also learned from administrator Luis Olivas that (R1) invoice statement was emailed to (R1) responsible party per (R1) request. The investigation also revealed that the facility uses “Realpage” to manage resident invoices and the portal only can hold one email. On 08/29/2023, It was learned that the facility made the changes to (R1) portal to have statements sent to (R1) instead. Based on LPA Lee observation on 09/14/2023, it was confirmed that (R1) invoices delivery will be emailed to (R1) instead. Moreover, per administrator, Luis Olivas (R1) monthly invoice will be emailed to (R1) responsible party through Outlook. LPA Lee also interviewed 9 out of 10 residents who stated they have no concern with their financial statements. Based on information provided through interviews and records reviewed, the allegation is deemed UNSUBSTANTIATED although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation staff is not providing a resident with a copy of financial statements.the state’s words, verbatim · CDSS document, Oct 19, 2023 · control 27-AS-20230911162731

From the deficiency page — Deficiency type: Type B · Section cited: CCR 1569.88(b) · Plan of correction due date: Oct 27, 2023

1569.884(b) Contents of residential care facility admission agreements (b) A comprehensive description of, and the fee schedule for, all items and services not included in a single fee. In addition, the agreement shall indicate that the resident shall receive a monthly statement itemizing all separate charges incurred by the resident. This requirement was not met as evidence by... Administrator did not ensure that a resident is receiving a monthly statement itemizing all separate charges incurred by the resident on resident's invoice statement.the state’s words, verbatim · CDSS document, Oct 19, 2023

Plan of correction: POC cleared during today's visit. On 09/08/2023 Administrator modify ledger entries to show itemized entry for resident incurred fees. Facility will ensure that (R1) recieves itemized ledger monthly.