Oakmont of North Fresno

Type of visit: Annual/Random

Licensing Program Analyst (LPA) Katie Brown arrived unannounced to conduct the continuation visit for the Annual Inspection. The initial inspection was conducted on 4/29/2026. LPA met with and discussed the reason for the visit with Administrator (AD) Heidi Setty. During this visit, LPA selected resident apartments to observe while touring with AD. Resident apartments were clean, in good repair and contained the required furnishings. LPA observed resident medication storage in their apartments and discussed the facility medication storage requirements. LPA conducted a medication audit in the medication room of the Assisted Living (AL) and reviewed medication and storage procedures with a facility Medication Tech. LPA reviewed the facility Plan of Operation as well as Emergency Disaster procedures, Fire and Emergency Drill logs which were complete and up to date. A deficiency is being cited in accordance with California Code of Regulations on the attached LIC 9099-D. The violation was observed and immediately addressed during the initial Annual Inspection on 4/29/26. The Deficiency has been Cleared. An exit interview was conducted. A copy of this report and Appeal Rights were discussed and provided.the state’s words, verbatim · CDSS document, May 20, 2026

Type of visit: Case Management - Other

Licensing Program Analyst (LPA) Katie Brown arrived unannounced to conduct a Case Management Visit. LPA met with and explained the reason for the visit with Administrator (AD) Heidi Setty. The purpose of today's visit is to remove the file of former Resident (R1). LPA Brown will return the file within three (3) working days. There were no citations issued during this visit. An exit interview was conducted and a copy of this report was provided to AD.the state’s words, verbatim · CDSS document, May 11, 2026

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Katie Brown arrived unannounced to conduct the Annual Inspection. LPA met with and explained the reason for the visit with Marketing Director, Mary Davis (MD) and Memory Care Director Andrea Yescas (MCD). LPA toured the facility inside and out. The Assisted Living (AL) and Memory Care (MC) areas of the facility were toured. LPA selected resident apartments to observe. Resident apartments were clean, in good repair and contained the required furnishings and lighting. LPA observed required items in bathrooms with faucets delivering hot water. LPA observed residents’ hygiene items, paper products, towels, bedding and linens which are available for use. LPA toured the facility kitchen while the culinary staff was preparing for lunch service. The kitchen was clean, with necessary items and appliances. LPA observed required perishable and non-perishable food supply. Food items were labeled and organized. Cleaning/disinfection supplies as well as safety and first Aid supplies were properly stored and available. LPA observed residents enjoying lunch in the dining rooms. There are multiple common areas available throughout the facility which were found to be clean and welcoming for residents and guests. Doors and passageways are unobstructed throughout the facility. Delayed egress was found to be in working order when exiting the MC section of the facility. Medications are locked and stored in medication rooms located in AL and MC. First Aid Kits are stored in Medication rooms and contained required items. Fire Extinguishers were charged by Fire Systems Solutions on 4/25/26. See Continuation on page 2 Page 2 During this visit, LPA conducted record reviews of resident and employee files. Infection Control and Emergency/Disaster Plans & procedures were reviewed. Due to time constraints, LPA will need to return to the facility another day to complete the remainder of this Inspection. There were no citations issued today. An exit interview was conducted and a copy of this report was provided.the state’s words, verbatim · CDSS document, Apr 29, 2026

Allegation investigated: Staff restricted resident's visitation rights

Licensing Program Analyst (LPA) Katie Brown arrived unannounced to conduct a subsequent complaint investigation and deliver findings. LPA explained the reason for the visit and discussed the allegation with Marketing Director (MD) Mary Davis. This Department investigated the allegation above. A record review and interviews were conducted. On 8/7/2025, facility staff informed a visitor of a visitation restriction policy in place for R1. The friend was informed that per the policy, they were not authorized to visit R1 in the Memory Care Neighborhood, which is where R1 resides. Interviews and record review confirm, there was not a legal court order put in place until 10/1/2025 pertaining to R1’s visitation. The preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. A deficiency is being cited in accordance with California Code of Regulations on the attached LIC 9099-D. An exit interview was conducted and Plan of Correction was developed. A copy of this report and Appeal Rights were provided. Substantiated R1's room and bathroom were clean and clothing was hung in the closet. Grooming, hygiene and incontinence supplies were observed and properly stored. Based on interview, record review and observation, the above allegations are UNSUBSTANTIATED. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove that the alleged violations did or did not occur. There were no citations issued. An exit interview was conducted and a copy of this report was provided.the state’s words, verbatim · CDSS document, Mar 4, 2026 · control 24-AS-20250926102526

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.1(a)(11) · Plan of correction due date: Mar 19, 2026

87468.1 Personal Rights of Residents in All Facilities (a) Residents... (11) To have their visitors,… permitted to visit privately during reasonable hours and without prior notice, provided that the rights of other residents are not infringed upon. This requirement was not met as evidenced by: Licensee did not ensure all residents were permitted to visit privately with guests without prior notice... On 8/7/25 staff informed a friend of R1 there was a visitation policy in place which restricted from the friend visiting R1 in Memory care which is where R1 resides. The visit had to be moved to the public bistro area. There was not a court order in place.the state’s words, verbatim · CDSS document, Mar 4, 2026

Plan of correction: AD has agreed to provide staff inservice on visitation related Personal Rights. Proof of training and training materials will be provided to CCLD via fax by poc date.

Allegation investigated: Staff are not using the residents preferred pharmacy

Licensing Program Analyst (LPA) Katie Brown arrived unannounced to conduct the initial complaint investigation. The Administrator (AD) Heidi Setty is out of the facility today. LPA explained the reason for the visit and discussed the allegation with Marketing Director (MD) Mary Davis. During this visit, LPA conducted a record review of Resident (R1's) Medication Administration Record (MAR) and Centrally Stored Medication Log. Interviews with facility LVN, R1's Responsible Party along with record review have confirmed the facility is ordering R1's medication from the correct pharmacy. This Agency has investigated the allegation listed above. We have found that the allegation is UNFOUNDED, therefore we have dismissed the allegation. There were no citations issued An exit interview was conducted and a copy of this report was provided. Unfoundedthe state’s words, verbatim · CDSS document, Mar 4, 2026 · control 24-AS-20260225092938

Allegation investigated: Staff did not seek appropriate therapy for a resident Facility is mismanaging residents medication.

Licensing Program Analyst (LPA) Katie Brown arrived unannounced to deliver investigation findings. LPA met with and discussed the allegation with Administrator (AD) Heidi Setty. This Department investigated the allegations listed above. Interview with the Administrator (AD) confirmed that any resident can receive any type of therapy once ordered by their Physician.R1's Physician has not ordered therapy and R1's Responsible Party has not requested the facility initiate this service for R1. A review of R1's current Physician ordered medications was conducted. An audit was conducted to confirm that medications ordered and available for use. The facility maintains communication with R1's Physician and Responsible Party as required. This Agency has investigated the allegations listed above. We have found that the allegations are UNFOUNDED, therefore we have dismissed the allegations. There were no citations issued. An exit interview was conducted and a copy of this report was provided. Unfoundedthe state’s words, verbatim · CDSS document, Jan 13, 2026 · control 24-AS-20250709100843

Allegation investigated: Staff are not following phyicians orders Staff does not ensure blood sugar testing is performed by an appropriately skilled professional Staff does not ensure blood insulin is administered by an appropriately skilled professional

Licensing Program Analyst (LPA) Katie Brown arrived unannounced to conduct a subsequent complaint visit to deliver investigation findings. LPA met with and discussed the allegation with Administrator (AD) Heidi Setty. This Department investigated the allegations listed above. LPA conducted interviews, reviewed Diabetic resident Medication Administration Records, staff schedules and timecards. The Reporting Party did not provide resident(s) identification information or a timeframe. Based on interview and record review the above allegations are UNSUBSTANTIATED. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove that the alleged violations did or did not occur. There were no citations issued. An exit interview was conducted and a copy of this report was provided. Unsubstantiatedthe state’s words, verbatim · CDSS document, Jan 13, 2026 · control 24-AS-20250707133233

Allegation investigated: Staff are not allowing resident to attend church services

Licensing Program Analyst (LPA) Katie Brown arrived unannounced to conduct a subsequent complaint visit. LPA met with and discussed the allegation with Administrator (AD) Heidi Setty. During this visit, LPA visited Memory Care and observed R1 and conducted record review. This Department has investigated the allegation above: Resident (R1) was restricted from leaving the facility with family on 6/29/25. On 6/28 and 6/29/25 staff referenced restrictions placed by R1's Public Guardian (PG) that approval was needed prior to R1 leaving the facility. Based on review of email coorespondence and interviews conducted, the facility followed the instructions put in place by PG on 6/26/25. The preponderance of evidence standard has been met, therefore the above allegations are found to be SUBSTANTIATED. A deficiency is being cited in accordance with California Code of Regulations on the attached LIC 9099-D. An exit interview was conducted and Plan of Correction was developed. A copy of this report and Appeal Rights were Substantiatedthe state’s words, verbatim · CDSS document, Jan 13, 2026 · control 24-AS-20250701091854

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.1(a)(6) · Plan of correction due date: Jan 20, 2026

87468.1 Personal Rights of Residents in All Facilities (a) Residents... (6) to leave or depart the facility at any time… This does not prohibit a licensee from establishing house rules..., This requirement was not met as evidenced by: Licensee did not ensure all residents could leave the facility at any time. On 6/29/25, R1 was restricted from leaving the facility to attend church per a restriction placed without a court order by the Public Guardian. This poses a potential health & safety risk to persons in care.the state’s words, verbatim · CDSS document, Jan 13, 2026

Plan of correction: AD has agreed to submit a written statement to include the immediate action taken to ensure the Personal Rights of R1 would be met. This statement will be signed by AD and submitted to CCLD by poc date.

Allegation investigated: Staff do not respond timely to a resident's alerts

Licensing Program Analyst (LPA) Katie Brown arrived unannounced to conduct a subsequent complaint investigation. LPA met with and explained the reason for the visit and discussed the allegation with Administrator (AD) Heidi Setty. During this visit, LPA reviewed pendent system report for the timeframe this complaint was filed. The report was reviewed with AD who provided explaination of the alert system markers and staff communication. The Reporting Party did not provide identifying information such as resident name or date range to be investigated. Based on interview and record review the above allegations are UNSUBSTANTIATED. Although the allegations may have happened or is valid, there is not a preponderance of evidence to prove that the alleged violations did or did not occur. There were no citations issued. An exit interview was conducted and a copy of this report was provided. Unsubstantiatedthe state’s words, verbatim · CDSS document, Jan 13, 2026 · control 24-AS-20250908113755

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

Licensing Program Analyst (LPA) Katie Brown arrived unannounced to conduct the initial complaint investigation at the facility. LPA met with and explained the reason for the visit with Martin Valenzuela (S1). Administrator (AD) Heidi Setty was contacted and authorized S1 to meet with LPA and sign the report. During this visit, LPA Conducted a record review, interviewed staff, toured resident apartments in Memory Care (MC) and observed residents in common areas of the MC wing of the facility. This Department investigated the allegations above: Resident (R1’s) Service Plan dated 4/19/25 states R1 requires standby assistance with set up for grooming and other hygiene related Activities of Daily Living (ADL) and R1 often refuses care and assistance. R1’s grooming and hygiene items were observed in R1’s room. Interview with staff confirm R1 often does not want to brush teeth or take a shower. Pictures of R1’s teeth were submitted for the purpose of this investigation. Based on interview and record review the above allegations are UNSUBSTANTIATED. Although the allegations may have happened or is valid, there is not a preponderance of evidence to prove that the alleged violations did or did not occur. There were no citations issued. An exit interview was conducted and a copy of this report was provided. Unsubstantiatedthe state’s words, verbatim · CDSS document, Sep 12, 2025 · control 24-AS-20250905082923

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

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

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

Licensing Program Analyst (LPA) Katie Brown arrived at the facility unannounced to conduct a subsequent complaint visit and deliver complaint findings. LPA met with and explained the reason for the visit with Administrator (AD) Heidi Setty. During the visit, LPA observed Resident (R1) in the common area. LPA observed R1's apartment, conducted interviews and reviewed records. The Department investigated the allegations listed above: Staff leave resident soiled causing skin rash: Per Service Plan dated 4/19/25 R1 uses incontinence supplies and frequently refuses staff assistance with care including toileting and bathing. Review of Medication Record reveals that R1 refuses taking medications including use of tpoical creams often. Staff interviews have conflicting reporting on R1's compliance with activities of daily living. See LIC9099C for continuation of this report Unsubstantiated Page 2 - Unfounded This Department investigated the following allegations: Staff do not ensure resident has adequate hygiene supplies: On 5/6, 7/1 and 7/14/25 R1's apartment was observed to have hygiene supplies. Hygiene items such as tooth and hair brushes were well maintained and properly stored. Staff were interviewed and consistently stated that when additional supplies are needed, they would communicate with the Med Tech or Nurse to contact the Responsible Party. Staff do not ensure resident's safety from another resident: During the interview with the RP, it was noted that this allegation was noted in a previously investigated complaint. Additionally, R1's Service Plan dated 4/19/2025 notes suspicious or accusatory behavior related to distrust of men in the past. This behavior has not been reported by staff since moving to a new, private room. Facility does not provide resident adequate meals: During visits at the facility on 5/6 and 7/1/25, R1 was observed eating lunch once, dinner twice in the dining room and multiple snacks in the common area with other residents. Snacks and beverages provided by family were also observed available in R1's room. Based on interviews and record reviews, R1 has memory loss and may not recall what was served or eaten at meals. Service plan and Physician Report also note Dementia and Memory Impairment. This Agency has investigated the allegations listed above. We have found that the allegations are UNFOUNDED, therefore we have dismissed the allegations. There were no citations issued An exit interview was conducted and a copy of this report was provided. Page 2 This Department investigated the following allegations: Staff do not follow Physician's Orders: Copies of R1's Physicians orders were provided to this Department for the purpose of this complaint investigation on 5/6/25 by the facility. R1's Public Guardian also provided a statement of R1's medications. The Reporting Party has also provided documents of medications which have been ordered over the span of multiple years by different physicians and specialists. Interviews reveal that the facility conducts communication related to R1's medication and medical changes with the court appointed Public Guardian. Staff do not ensure resident's hygiene needs are met: R1 was observed on 5/6, 7/1 and 7/14/25 at the community. On 5/6 and and 7/1/25 R1 had been assisted with a shower. All dates listed above, R1 was observed in clean clothing wearing appropriate shoes. R1 was noted to be in the activity or seating area. R1's Service Plan dated 4/19/25 notes that R1 frequently refuses assistance with bathing or hygiene care. Staff do not allow resident visitation: R1 has a court appointed Public Guardian. Record review and Interviews have been conducted which outline the visitation for R1. Multiple interviews were conducted related to R1's visitations and visitors at the facility, the reports were inconsistent. Email communication was provided by different parties involved in R1's care for review which provides documentation of the visitation agreement. Based on interview and record review the above allegations are UNSUBSTANTIATED. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove that the alleged violations did or did not occur. There were no citations issued. An exit interview was conducted and a copy of this report wasthe state’s words, verbatim · CDSS document, Jul 14, 2025 · control 24-AS-20250430083718

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

Licensing Program Analyst (LPA) Katie Brown arrived at the facility unannounced to conduct the initial complaint investigation. LPA spoke to Administrator (AD) Heidi Setty on the phone during the visit. LPA met with and explained the reason for the visit and the elements of the allegations with Marketing Director, Mary Davis. LPA delivered investigation findings to the facility during this visit. This Department investigated the allegation: Facility does not ensure Physician ordered diets and restrictions are followed. Staff interviews were conducted which revealed the facility procedure for communication with chef/kitchen staff. Record Review of Resident Dietary Information was conducted and LPA observed dinner being served in Memory Care. Specific resident information was not provided. Based on interview and record review the above allegations are UNSUBSTANTIATED. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove that the alleged violation did or did not occur. There were no citations issued. An exit interview was conducted and a copy of this report was provided. Unsubstantiatedthe state’s words, verbatim · CDSS document, Jul 1, 2025 · control 24-AS-20250627110501

Type of visit: Annual/Random

Licensing Program Analyst (LPA) Katie Brown arrived unannounced to complete the Annual Inspection which was started on 4/29/25. LPA met with and explained the reason for the visit with Nathaniel Domingez (LVN), Andrea Yescas Memory Care Director (MCD) and Administrator (AD) Heidi Setty. LPA began the inspection today with a tour of Memory Care. LPA randomly selected resident apartments. Apartments were found to be clean, in good repair, containing required equipment, furnishings and lighting. LPA observed required items in bathrooms which were clean with hot water measuring between 105-108 degrees throughout. LPA observed hygiene items, paper products, towels, extra bedding, and linens which were stored and available for use. Many residents were observed participating in activities in common areas. LPA conducted resident and staff file reviews as well as a medication audit. Emergency Disaster and Infection Control procedures and plans were reviewed during the inspection. Deficiencies are being cited in accordance with California Code of Regulations on the attached LIC 809-D. An exit interview was conducted and Plans of Correction (POC) developed. A copy of this report and Appeal Rights were provided. LPA requested the following updated forms faxed to CCLD by 5/15/25 - Designation of Facility Responsibility (Lic308), Administrative Organization (Lic309), Personnel Report (LIC 500), Client Roster (LIC 9020) and Proof of current Liability Coveragethe state’s words, verbatim · CDSS document, May 6, 2025

The state marks this report as 9 pages; the online copy we transcribed has 5. You can request the full file from the county licensing office.

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Katie Brown arrived unannounced to conduct the Annual Inspection. LPA met with and explained the reason for the visit with Administrator (AD) Heidi Setty, Health Services Director Nathaniel Domingez (LVN) and Memory Care Director (MCD) Andrea Yescas LPA entered the lobby to find well lit common areas with multiple seating areas and a bistro. Required postings were observed. LPA began the facility tour which included randomly selected resident apartments. LPA toured resident apartments in both Assisted Living (AL) and Memory Care (MC) areas of the facility. Apartments were found to be clean, in good repair, containing required equipment, furnishings and lighting. LPA observed required items in bathrooms which were clean with hot water measuring between 105-108 degrees throughout. LPA observed hygiene items, paper products, towels, extra bedding, and linens which were stored and available for use. Residents were observed participating in activities or common areas in both AL and MC. There is a Medication room located in both AL and in MC. The main kitchen is located on the AL side of the facility. The kitchen was found to be clean, organized and in good repair with necessary preparation items and appliances. LPA observed required food supply, emergency food, water, and paper products. Cleaning/disinfecting supplies and chemicals are properly stored and available. Doors and passageways are unobstructed throughout the facility including outdoors. LPAs walked the outdoors to find the grounds well-kept with clear walkways with sitting areas. The Delayed Egress doors from MC to AL were found in working order. Fire extinguishers were charged and serviced 1/14/25 by Fire Systems Solutions. During today’s inspection, LPA conducted resident file review and a medication audit. Due to time constraints, LPA will need to return to the facility to complete this Annual inspection. An exit interview was conducted. This report was signed and a copy was provided to AD.the state’s words, verbatim · CDSS document, Apr 29, 2025

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

Licensing Program Analyst (LPA) Katie Brown arrived unannounced to deliver investigation findings. LPA met with and explained the reason for the visit with Administrator (AD) Heidi Setty. This department investigated the allegation: Staff left resident in soiled undergarments for an extended period of time. Record review of R1's care plan and interviews confirm that Resident R1 is independent in toileting and prefers to wear disposable underware. R1 is not on a toileting program though staff offer to assist R1 who often refuses the help. This department investigated the allegation: Staff did not ensure resident's grooming needs are being met. R1 was observed on 9/25/24 and 2/3/25 to be well groomedd, and wearing clean clothess. R1's personal grooming items were also observed on the dates above. An interview with the facility podiatrist confirms that the Dr, attempts to provide treatment with each visit and R1 usually refuses. It was confirmed that the podiatrist visits are covered by R1's insurance. See LIC9099C for the continuation of this report Unfounded Based on observation, Record Review of R1's file and interviews, we have found that the allegations are UNFOUNDED, therefore we have dismissed the allegation. There were no citations issued An exit interview was conducted and a copy of this report was left with AD, whose signature confirms receipt of this report.the state’s words, verbatim · CDSS document, Feb 3, 2025 · control 24-AS-20240920162946

Type of visit: Case Management - Other

Licensing Program Analyst (LPA) Katie Brown conducted a Case Management visit in conjunction with an initial complaint visit. During this visit, LPA met with Administrator (AD) Heidi Setty and Memory Care Director (MCD) Andrea Yescas. During this visit, LPA and MCD toured Memory Care resident apartments. During the tour, LPA observed a disposable razor stored in an unlocked bathroom cabinet. The razor was immediately removed by MCD. A deficiency is being cited in accordance with California Code of Regulations on the attached LIC 809-D in the area of: Care of Persons with Dementiathe state’s words, verbatim · CDSS document, Sep 25, 2024

Type of visit: Required - 1 Year

Licensing Program Analysts (LPA) Katie Brown and Lissett Paggett arrived unannounced to conduct the Annual Inspection. LPA met with and explained the purpose of the visit with Administrator (AD) Heidi Setty. During this visit, LPAs toured the facility inside & out which included multiple resident apartments in Assisted Living (AL) as well as Memory Care (MC). Resident apartments are found to be in good repair and contained required furnishings and lighting. The resident bathrooms were clean and in good repair with faucets delivering hot water within required limits. LPAs observed required hygiene items, grab bars and non skid showers. Towels, extra bedding, and linens were stored and available for use. The kitchen was clean, with necessary items and appliances. LPAs observed required food supply and paper product storage. Cleaning/disinfecting supplies and chemicals are locked and stored separate from food. Medications are centrally stored in medication rooms. First aid kits contained required items. There are multiple visitation areas available inside and out. Doors and passageways are unobstructed throughout the facility. The delayed egress doors were working properly which lead to MC. The fire detection system was last serviced 4/11/24 by Fire System Solutions, Inc. The Fire extinguishers were serviced 1/9/2024. LPAs conducted resident and staff file reviews including medication audit. Emergency Disaster Plan and Infection Control Plans were reviewed during this visit. Deficiencies are being cited in accordance with California Code of Regulations on the attached LIC 809-D in the areas of Incidental Medical and Dental, Residents with Special Health Needs and Storage Space. Civil Penalties are being assessed on the attached LIC421F for repeat violations. See LIC809C for continuation of this report An exit interview was conducted and Plan of Corrections (POC) were developed. A copy of this report was signed by AD. Appeal Rights were also provided. LPA requested the following updated forms faxed to CCLD by 4/4/2024: Designation of Facility Responsibility (Lic308), Administrative Organization (Lic309), Affidavit Regarding Client/Resident Cash Resources (LIC 400), Emergency Disaster Plan (LIC610E), Personnel Report (LIC 500), Client Roster (LIC 9020), Proof of current Liability Coverage.the state’s words, verbatim · CDSS document, Apr 16, 2024

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

Licensing Program Analyst(LPA) Katie orwn arrived at the facility unannounced to deliver the complaint findings. LPA met with Administrator (AD) Heidi Setty. The Department investigated the allegations listed above. Interviews and record review of R1’s hospice care plan and facility documentation reveal that on 3/10/23, R1’s hospice care plan was not followed resulting in R1 falling while being assisted by hospice aid and facility care staff. The care plan (certification period 2/3/23 – 3/30/23) notes that R1 will receive a bed bath. On 10/10/22, Resident (R2) was located by staff after exiting the facility resulting in Absence Without Leave (AWOL). R2 was found walking down the street off facility grounds. R2’s Physician’s Report dated 4/29/22 states R2 cannot leave the facility unassisted. See Lic9099C for continuation of this report Substantiated Interview and record review of facility documentation of the incident reveal that R1 experienced a fall in the shower while being assisted by hospice aid and facility care provider. Written statements from both as well as the chart note by Med Tech include that R1’s head came in contact with the wall during a fall. The facility did not report the incident to CCLD as required. Deficiencies are being cited in accordance with California Code of Regulations on the attached LIC 9099-D in the areas of Personnel Requirements, Hospice Care of Terminally Ill Residents and Reporting Requirements. An exit interview was conducted and Plan of Correction was developed. A copy of this report and Appeal Rights were signed and emailed to AD Hsetty@oakmontmg.com.. Based on observation, interview, and record review the Department is unable to determine if Activities of Daily Living (ADLs) and basic services were provided to R2. LPA visited the facility multiple times between 9/12/23 and 12/12/23 and observed water available during and in between meals as well as residents being assisted to eat. Record review of facility chart notes and emails show that between 3/8/23 – 4/8/23 housekeeping and hands on care service was increased for R2 due to increased need. This additional care was suspended 4/8/23. Hospice records do not mention basic services not being provided. Hospice records document that R2 continued to lose weight between 10/2022 – 8/2023 related to disease process and minimal/poor food intake. Based on record review, an order was written for R2 to receive weekly routine lab work on 7/18/22. R2 was admitted to hospice 10/25/23. R2's facility and hospice records were obtained and reviewed. It is not able to be determined when or if this routine order was discontinued. Additionally, the hospice agency ordered lab work to be done 3/14/23 which was scheduled by the facility to be completed 3/20/23. The hospice agency revised that order for the lab work to be conducted sooner by a mobile service. Based on interview, record review and observation, the above allegations are UNSUBSTANTIATED. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove that the alleged violations did or did not occur. There were no citations issued An exit interview was conducted and a copy of this report was signed by AD and emailed to HSetty@oakmontmg.comthe state’s words, verbatim · CDSS document, Jan 12, 2024 · control 24-AS-20230911151045

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87633(a)(4) · Plan of correction due date: Jan 15, 2024

87633 Hospice Care of Terminally Ill Residents (a) The licensee shall be permitted... receive hospice services from a hospice agency in the facility…(4) A written hospice care plan which specifies the care, services... all hospice care plans are fully implemented by the licensee and by the hospice(s). This requirement was not met as evidenced by: Licensee did not ensure R1's hospice care plan was implemented. R1 received a shower by staff and hospice aid of the wrong agency. R1's careplan specifies a bed bath to be given. R1 sustained a fall during this shower. This poses an immediate health & safety risk to persons in care.the state’s words, verbatim · CDSS document, Jan 12, 2024

Plan of correction: AD has agreed to provide a written statement which will include the review and in-service plan which will be completed by the facility. The statement will be submitted by 5pm 1/15/24. AD has agreed that all appropriate staff will recieve in-service on the individualized hospice care plans and to ensure proper communication between staff communication. A signed in-service will be submitted to CCLD via email by the POC date.

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87411(d)(3) · Plan of correction due date: Jan 15, 2024

87411 Personnel Requirements – General(d) All personnel shall be given on the job training…training shall provide knowledge of and skill in the following, as appropriate for the job assigned and as evidenced by safe and effective job performance: (3) Skill and knowledge required to provide necessary resident care and supervision..., This requirement was not met as evidenced by: Licensee did not ensure supervision of R2 who exited the Dementia wing and walked out of the facility on 3/10/23. R1's whereabouts were unknown by the facility. This poses an immediate health & safety risk to persons in care.the state’s words, verbatim · CDSS document, Jan 12, 2024

Plan of correction: AD has agreed to provide a written statement which will include the review and in-service plan which will be completed by the facility. The statement will be submitted by 5pm 1/15/24. AD has agreed to conduct an elopement drill for all shifts. A sign in sheet will be submitted to ccld once all appropriate staff have reviewed and practiced elopement procedures. Facility conducted elopement inservice on 12/28/23. Sign in will be emailed to ccld by POC date.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87411(a)(1)(D) · Plan of correction due date: Jan 22, 2024

87211 Reporting Requirements (a) Each licensee shall furnish to the licensing agency such reports… (1) A written report shall be submitted… (D) Any incident which threatens the welfare, safety or health of any resident… This requirement was not met as evidenced by: Licensee did not ensure an Incident Report was submitted to CCLD when R1 fell and hit head while receiving a shower by the wrong hospice agency and facility staff member. This poses a potential health & safety risk to persons in carethe state’s words, verbatim · CDSS document, Jan 12, 2024

Plan of correction: AD has agreed to review the facility reporting procedure with the other Directors involved. A written statement will be submitted to include revised evaluation process of determining what incidents are reported to CCLD. AD and Directors will sign the statement which will be emailed to CCLD by POC date

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

Licensing Program Analyst (LPA) Katie Brown arrived at the facility unannounced to conduct a subsequent complaint visit and deliver investigation findings to the facility. LPA explained the reason for the visit with Administrator (AD) Heidi Setty. During this visit, LPA observed Resident (R1's) apartment and lunch dining service. LPA also conducted interviews and obtained documents from R1's facility file for record review. The Department conducted an investigation of the allegations stated above. Interview and record review reveal that R1's inventory list,has been maintained by a family member, not the facility. R1's apartment was toured on 8/9/23, 8/17/23, 11/16/23 and 12/12/23 where blankets, towels and a clean couch cover were observed. Soiled clothing was not observed in R1's closet or drawers on these dates. There are not Housekeeping records to indicate that services were or were not provided as reported. Based on interviews, R1's room and personal items are cleaned up daily to avoid R1 wearing soiled items. Unsubstantiated Interviews were conducted regarding staff taking pictures of residents on personal phones. Conflicting information was provided. Staff who were interviewed deny having knowledge of or taking resident pictures. Record review of Medication Administration Records (MARs) from July, August, November and December 2023 record staff document when R1 takes or refuses medications. Interviews and observation reveal that residents are served appropriate portions of food. Snacks are sscheduled and served throughout the day and are available are available in the Memory Care (MC) kitchen. The above allegations are UNSUBSTANTIATED. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove that the alleged violations did or did not occur. There were no citations issued An exit interview was conducted and a copy of this report was emailed to AD who signed the reports.the state’s words, verbatim · CDSS document, Dec 12, 2023 · control 24-AS-20230809115225

Type of visit: Case Management - Other

Licensing Program Analyst (LPA) Katie Brown arrived at the facility unannounced to conduct a Case Management visit in conjunction with a complaint (Control Number 24-AS-20230809115225). LPA explained the purpose of the Case Management with Administrator (AD) Heidi Setty. During an interview related to the complaint mentioned above, additional concerns were reported to LPA regarding Resident (R1). LPA conducted additional interviews and record review during this visit. There were no citations issued An exit interview was conducted and a copy of this report was emailed to AD who signed the reports.the state’s words, verbatim · CDSS document, Dec 12, 2023

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

Licensing Program Analyst (LPA) Katie Brown arrived at the facility unannounced to conduct a subsequent complaint investigation. LPA met with Memory Care Director (MCD) Andrea Yescas. During this visit, LPA conducted resident interviews and reviewed staff records. The Department investigated the allegations ablove. LPA conducted multiple visits to the facility during the course of this investigation. R1 was observed each time to be clean and in clean clothing. During these visits, R1 was observed using the public telephone, watching television, participating in group activities or eating in the dining room. R1's room and bathroom were clean during LPA visits. Photos were provided of a brown substance which may have been feces on the toilet and surrounding areas. Staff interviewed state that this may occur due to R1 and R2 using the toilet independently without being able or aware of sufficient cleaning. LPA observed the chairs, tables and floors of the dining room to be clean during visit See Lic9099-C for continuation of this report Unsubstantiated Residents and staff were interviewed and did not report seeing or having knowledge of staff yelling at or treating residents inappropriately. Doors to resident rooms can be locked from either side but automatically unlock when the knob is turned from inside the room. Staff interviews and record review of charting notes and staff assignment forms reveal that R1 often refuses medications, physician ordered treatments and ADL care such as showers or hygiene assistance. LPA toured multiple resident rooms and did not find rooms to have permanent odor. Interviews revealed and LPA observed that R1 dresses self in multiple layers or mismatched clothing. Medication orders and medications were observed to be up to date. LPA observed documentation of communication with R1's Legal Guardian regarding medications and medical appointments. Night shift training records were observed to have met requirements. Based on interviews conducted, LPA observations and record reviews the above allegations are UNSUBSTANTIATED. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove that the alleged violation did or did not occur. There were no citations issued An exit interview was conducted and a copy of this report was left with MCD, whose signature confirms receipt of these documents.the state’s words, verbatim · CDSS document, Nov 16, 2023 · control 24-AS-20230808141453

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

Licensing Program Analyst (LPA) Katie Brown arrived at the facility unannounced to conduct the initial 10-Day complaint investigation. Upon entry, LPA met with Marketing Director (MD) Mary Davis. Administrator (AD) Heidi Setty and Health Services Director (HSD) Nathaniel Domingues arrived shortly after. LPA explained the reason for the visit and the elements of the allegation. During the visit, LPA conducted record review of Resident (R1's) file as well as interviewed AD and HSD. Interviews reveal a discrepancy in whether proper notification of physician ordered lab work was communicated to R1’s Responsible Party. Facility charting notes and shift report document that a message was left by staff. Interview and record review of the Residence and Service Agreement (RSA) reveal that pharmacy designation is part of the admission process but not an element of the RSA. See Lic9099-C for continuation of this report Unsubstantiated Though medication was ordered from the wrong pharmacy, it was not found to be a violation of the agreement. The above allegation is UNSUBSTANTIATED. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove that the alleged violation did or did not occur. There were no citations issued An exit interview was conducted and a copy of this report was left with AD, whose signature confirms receipt of these documents.the state’s words, verbatim · CDSS document, Nov 16, 2023 · control 24-AS-20231114150812

Allegation investigated: Staff mismanaged resident's medications.

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

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87465(a)(6) · Plan of correction due date: Nov 14, 2023

87465 Incidental Medical and Dental Care (a) A plan for incidental medical and dental care shall be developed by each facility… by compliance with the following: (6) When requested... or the Department, a record of dosages of medications which are centrally stored shall be maintained by the facility. This requirement was not met as evidenced by: Licensee did not ensure that a record was maintained of medications that were centrally stored for R1. Multiple medications were accepted and stored by the facility but an accurate/up to date Centrally Stored Medication and Destruction Record (CSMDR) was not maintained. Received and start dates are not recorded for multiple medications from April-August 2023. This poses a potential health & safety risk to persons in care.the state’s words, verbatim · CDSS document, Nov 6, 2023

Plan of correction: AD has agreed to provide an inservice to appropriate staff which reviews the procedure for centrally stored medication acceptance and documentation. A sign in sheet will be submitted which records the training agenda as well as name and signature of staff attending the inservice. The sign in sheet and supporting materials used will be submitted to CCLD via email by the POC date.

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

Licensing Program Analyst (LPA) Katie Brown arrived unannounced to conduct a subsequent complaint visit and deliver investigation findings to the facility. LPA met with and explained the reason for the visit with Administrator (AD) Heidi Setty. The Department has investigated the allegations listed above. LPA observed Resident (R1) and R1's room which was found to be clean and odor free on 7/6/23 and 10/16/23. Furniture and assistive devices were stored appropriately and neatly. R1 was observed clean and resting comfortably in bed. LPA observed R1 properly positioned during meals. During this visit, LPA conducted staff and Hospice Nurse interviews. LPA reviewed R1's file including facility's daily Staff Assignment Log for June - October 2023, Housekeeping and staff schedules were also reviewed. Based on observation, interview and record review, the above allegations are UNSUBSTANTIATED. Although the allegatiosn may have happened or are valid, there is not a preponderance of evidence to prove that the alleged violations did or did not occur. There were no citations issued An exit interview was conducted and a copy of this report was left with AD, whose signature confirms receipt of these documents. Unsubstantiatedthe state’s words, verbatim · CDSS document, Oct 16, 2023 · control 24-AS-20230630095305

The state marks this report as 3 pages; the online copy we transcribed has 1. You can request the full file from the county licensing office.

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

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

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Katie Brown arrived unannounced to conduct a Case Management - Incident visit. LPA met with and explained the reason for the visit with Administrator (AD) Heidi Setty. LPA conducted the Case Management to follow up on an incident which occurred on 10/12/2023. The incident resulted in resident R1 going absent without leave (AWOL). R1 was out of the building approximately 13 minutes. During the visit, LPA interviewed AD and R1 and a record review was conducted. It was confirmed that R1 was placed on the Wandergard program the same day the incident and the resident reappraisal is in process. A deficiency is being cited in accordance with California Code of Regulations on the attached LIC 9099-D An exit interview was conducted and Plan of Correction was developed. A copy of this report and Appeal Rights were discussed and left with AD, whose signature on this form confirms receipt of these documents.the state’s words, verbatim · CDSS document, Oct 16, 2023

From the deficiency page — Deficiency type: Type B · Section cited: HSC 1560.312 · Plan of correction due date: Oct 17, 2023

§1569.312 Basic services requirements Every facility required to be licensed under this chapter shall provide at least the following basic services: (a) Care and supervision as defined in Section 1569.2. *This requirement was not met as evidenced by: Licensee did not ensure the care and supervision to R1. R1 AWOL the facility 10/12/23. R1's Physician's Report (PR) states R1 cannot leave the facility unassisted. Per PR, R1 has diagnosis of Dementia. This poses a potential health and safety risk to residents in carethe state’s words, verbatim · CDSS document, Oct 16, 2023

Plan of correction: R1 has been placed on the facility Wanderguard program. Reappraisal of R1 is in process. DEFICIENCY CLEARED during this visit.

The state marks this report as 2 pages; the online copy we transcribed has 1. You can request the full file from the county licensing office.