Oakmont of Roseville

Type of visit: Annual/Random

Licensing Program Analyst (LPA) Graham Gunby arrived unannounced to conduct the Required 1-year annual inspection. LPA met with Executive Director (ED) Angelique Doyle and explained the purpose of the visit. Currently there are eighty-seven (87) residents of which five (5) residents are receiving hospice services. LPA was unable to open the CARE tool during inspection. LPA toured facility with ED to ensure health and safety of residents in care. LPA toured resident rooms, medication room, bathrooms, kitchen, common living spaces, outdoor spaces, and activity areas. In the areas toured no immediate health, safety, or personal rights violations were observed. LPA toured the assisted living side of the facility and the memory care unit with a delayed egress. There is a locked storage for medications and toxins. Food supply is adequate for 2-day perishable and 7-day nonperishable. Fire extinguishers were last serviced on 08/09/2026. LPA reviewed eight (8) resident files. Resident files contained all required signed documentation including admission agreements, appraisals, medical assessments, consent and personal rights forms. LPA reviewed five (5) staff files. A review of staff records indicates that all facility staff has received criminal record clearances, health screenings, and CPR training. No deficiencies are being cited as a result of todays inspection. Exit interview conducted and copy of the report was emailed to ED.the state’s words, verbatim · CDSS document, Aug 31, 2026

Allegation investigated: Staff did not answer residents' call buttons in a timely manner.

Licensing Program Analyst (LPA) Graham Gunby arrived on 06/30/2026 to deliver findings to a complaint the department received on 01/23/2026. LPA met with Executive Director, Angelique Doyle, and explained the purpose of this visit. During the interview process, the Executive Director and carestaff that worked with the resident were interviewed. The resident was not interviewed, as R1 and R2 has moved. Documents received and reviewed were the average call button times. The administrator and staff persons reported that they typically respond to call button times within 5-20 minutes. It was reported that if one of the staff persons are busy with one resident, they will radio to another staff person to assist and respond to a second resident. Staff indicated that they work well together to try and meet all resident’s needs in a timely manner. The administrator stated that the average response time is between a 5-20 minute time frame. The call logs showed staff responding to call buttons in a timely manner. Although the allegation may have happened or are valid, there is not a preponderance of evidence to prove that the alleged violations occurred, and the findings are UNSUBSTANTIATED. Nothe state’s words, verbatim · CDSS document, Jun 30, 2026 · control 59-AS-20260123102832

Type of visit: Required - 1 Year

On August 29, 2025, Licensing Program Analyst (LPA) Cassie Yang arrived unannounced at the facility to conduct a required annual inspection. LPA met with Executive Director (ED), and explained the purpose of the visit. Today's census is 76 residents in care, with four residents on hospice. Facility is licensed for 120 residents, hospice waiver of 15. Today's inspection, LPA and ED conducted a tour of the interior and exterior of the facility to ensure the health and safety of residents in care. Areas toured included but not limited to: facility courtyards, library, private dining room, main dining rooms, activity room, fitness center, media room, laundry room, business office and residents bedrooms and bathrooms. LPA observed fire extinguisher present throughout the facility with recent service date of August 13, 2025. LPA observed residents in care, participating in yoga session. LPA observed residents playing bingo in the activity room. LPA observed residents to be doing physical therapy in the fitness center. In areas toured, LPA observed no health, safety and personal rights violations. LPA conducted a file review of eight resident records and eight personnel records. LPA observed resident records to have the required documents completed. LPA observed personnel records to have required initial training. When asked, Business Director informed LPA that not all care providers are provided cardiopulmonary resuscitation (CPR) training. Business Director stated all culinary staff, working 6 AM to 8 PM, are CPR certified. Additionally, the care providers and medication technicians on nocturnal (NOC) shift are CPR certified to ensure that at least one staff member who has CPR training and first aid training is on duty and on the premises at all times. Continue LIC 809-C LIC 809-C LPA completed the CARE tool and found facility to be compliance. At this time, LPA is requesting a copy of liability insurance and LIC 308 to be emailed to LPA by September 5, 2025. As a result of today's visit, no deficiencies cited. At time of exit interview, ED was unavailable. Report was signed with Business Director. Exit interview conducted and a copy of report was provided.the state’s words, verbatim · CDSS document, Aug 29, 2025

Allegation investigated: -Staff mismanaged resident's medications -Staff did not ensure resident's incontinence care needs were met resulting in an infection -Staff did not ensure resident hygiene care needs were met

Licensing Program Analyst (LPA) Angela Hood arrived at the care home today and met with the Vice President of Operations, Terry Ervin, to deliver complaint investigation findings regarding the above stated allegations. During the course of the investigation, LPA conducted interviews, a medication count, and obtained documentation pertinent to the investigation. On April 8, 2025, LPA conducted a medication count for residents (R9, R10, and R11), comparing the residents’ medication lists on file with medication centrally stored for the residents. LPA did not observe any medication errors. LPA was unable to complete a medication count for resident (R1) as they have moved out of the care home. Interviews with residents (R2, R3, R4, R6, and R7) indicated that they receive all medications as prescribed. Interviews with witness (W1) and staff (S3 and S5) indicated that medications are being given as prescribed. *********************************************Continued on LIC9099-C************************************************** Unsubstantiated R1's Assessment conducted on November 21, 2024, and R1's Individualized Service Plan, dated November 21, 2024, indicated that R1 required complete assistance with toileting needs and has difficulty maintaining acceptable hygiene standards. R1 required hands on assistance with all grooming and hygiene tasks. R1 required total assistance and/or an additional caregiver for all showering/bathing needs 3-4 times per week. R1 required total assistance with dressing and undressing and assistance with clothes selection 2 times per day. R1 also required hands on assistance with cleaning and/or storing dentures in appropriate container. According to the December 2024 Staff Assignments log, staff initialed each time they aided with toileting according to schedule, need and requests, as well as ordering and maintaining inventory of incontinence products, clothing and linen according to need. Staff also initialed each time they aided with grooming, bathing, dressing, and denture care. The only missing entries were when R1 was hospitalized. R1's Assessment conducted on November 21, 2024, and R1's Individualized Service Plan, dated November 21, 2024, indicated that R1 expresses frustration or reluctance when receiving assistance with Activities of Daily Living (ADLs) but generally cooperates, minimal staff time is needed. Interviews with staff (S2) and S3 indicated that it was difficult for care staff to provide R1 assistance with ADLs. S2 and S3 indicated that R1 would become combative, however, they were still able to provide R1 care. S3 and staff (S4) indicated that, when it is difficult to provide care to a resident, the care staff team up to assist each other in providing care. W1 indicated that facility provides all care needs. R2, R3, R4, R5, R6, and R7 indicated that they are receiving assistance with all their care needs from facility staff. Home Health Nurse indicated that R1 didn't seem unkept. Home Health Nurse indicated that they never conducted a urine analysis when R1 resided at the facility. According to facility Charting Notes, R1 was sent to the hospital on December 9, 2024, returning the same day with a UTI and a prescription for antibiotics. Emergency Department records, dated December 9, 2024, indicated that R1 sustained a fall at the facility. Records indicated that there was no evidence of injury, however, they were awaiting urine analysis results for suspected UTI. Records indicated that an antibiotic was started for potential UTI in the Emergency Department and a new prescription was ordered to continue medication upon discharge. Facility Charting Notes indicated that, on the evening of December 10, 2024, R1 had shortness of breath and was wheezing *******************************************Continued on LIC9099-C****************************************************** so was sent to the hospital. After Visit Summary, dated December 15, 2024, indicated that R1 was admitted on December 10, 2024, and discharged on December 15, 2024. R1 was found to have COPD exacerbation with associated severe sepsis. R1 was started on additional medication. Upon discharge from the hospital, R1’s COPD exacerbation and associated severe sepsis had resolved. Based on medication count, interviews conducted, and documentation obtained, although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur. Therefore, the allegations are UNSUBSTANTIATED. No deficiencies are being cited. Exit interview conducted. A copy of the report was provided.the state’s words, verbatim · CDSS document, May 8, 2025 · control 59-AS-20241230142101

Type of visit: Case Management - Deficiencies

Licensing Program Analyst (LPA) Angela Hood arrived at the care home today and met with the Vice President of Operations, Terry Ervin to conduct a case management visit in relation to a separate inspection conducted on today's date, May 8, 2025. On May 8, 2025, the facility was unable to provide LPA resident (R1's) LIC622 Centrally Stored Medication and Destruction Record as well as any LIC624 Unusual Incident/Injury Reports pertaining to R1. R1's complete record of centrally stored prescription medications shall be maintained for at least one year. R1 was hospitalized on December 9, 2024 and December 10, 2024 requiring a written report to be submitted to the department within seven days of the occurrence. However, the department and facility do not have written record of R1's hospitalization incidents. As a result of today's inspection, deficiencies are being cited pursuant to California Code of Regulations, Title 22, Division 6, Chapter 8. Deficiencies are listed on 809-D pages. Exit interview was conducted. A copy of this report and appeal rights were provided.the state’s words, verbatim · CDSS document, May 8, 2025

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87465(h)(6) · Plan of correction due date: May 22, 2025

87465 Incidental Medical and Dental Care (h) The following requirements shall apply to medications which are centrally stored: (6) The licensee shall be responsible for assuring that a record of centrally stored prescription medications for each resident is maintained for at least one year... This requirement is not met as evidenced by: Based on interviews conducted, the facility was unable to provide LPA with resident (R1's) complete record of centrally stored prescription medications, which poses a potential health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, May 8, 2025

Plan of correction: Facility agrees to complete a statement of understanding as well as conduct a training with all staff that handle medications regarding the importance of medication documentation. Facility will submit to LPA by the POC due date of 5/22/2025.

From the deficiency page — Deficiency type: Type B · Section cited: CCR87211(a)(1) · Plan of correction due date: May 22, 2025

87211 Reporting Requirements (a) Each licensee shall furnish to the licensing agency such reports as the Department may require, including, but not limited to, the following:(1) A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence 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 requirement was not met as evidenced by: Based on interviews conducted, the facility was unable to provide LPA with any incident reports regarding R1's hospitalizations, which poses a potential health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, May 8, 2025

Plan of correction: Facility agrees to complete a statement of understanding and submit to LPA by the POC due date of 5/22/2025.

Type of visit: Case Management - Deficiencies

Licensing Program Analyst (LPA) Angela Hood arrived at the care home today and met with the Senior Health Services Director, Lori Gales, to conduct a case management visit in relation to a separate inspection conducted on today's date, 04/16/2025. On 04/08/2025, the facility was unable to provide LPA documentation requested from resident (R1's) file as the documents were locked in the storage that the Executive Director (ED) has access to. On 04/16/2025, the facility was unable to provide LPA incident reports involving R1 as they were locked in the ED's cabinet. The ED was not present in the facility on both dates. Documents are to be readily available to CCL upon request. As a result of today's inspection, deficiencies are being cited pursuant to California Code of Regulations, Title 22, Division 6, Chapter 8. Deficiencies are listed on 809-D pages. Exit interview was conducted. A copy of this report and appeal rights were provided.the state’s words, verbatim · CDSS document, Apr 16, 2025

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87506(a) · Plan of correction due date: Apr 30, 2025

87506 Resident Records (a)The licensee shall ensure that a separate, complete, and current record is maintained for each resident in the facility or in a central administrative location readily available to facility staff and to licensing agency staff. This requirement is not met as evidenced by: Based on interview conducted, the facility was unable to provide LPA with requested documents on 04/08/2025 and 04/16/2025, which poses a potential health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Apr 16, 2025

Plan of correction: Facility will provide LPA with a statement of understanding, as well as a plan to ensure all documents are readily available to CCL. Facility will submit to LPA by the POC due date of 04/30/2025.

Type of visit: Case Management - Other

Licensing Program Analyst (LPA) Cassie Yang conducted unannounced case management visit on 09/13/2024. This visit is to confirm ORDERS TO INDIVIDUAL FOR IMMEDIATE EXCLUSION FROM ALL FACILITIES. LPA met with concierge Nancy Glensor and additionally LPA spoke with Executive Director, James Dial, on the phone and stated the purpose of visit. Facility understands this is an Immediate Exclusion effective 09/13/2024 and S1 is excluded and cannot be allowed to work, live in, and/or have contact with clients in any residential facility licensed by the California Department of Social Services. Therefore, the Department orders the facility to remove S1 from any contact with clients and not allow this employee to be physically present in the facility. Exit interview conducted, a copy of this report provided on this date. A signature on these forms acknowledges receipt of these forms.the state’s words, verbatim · CDSS document, Sep 13, 2024

Type of visit: Post Licensing

On 6/20/2024, Licensing Program Analyst (LPA) Cassie Yang arrived to the facility unannounced to conduct a required annual inspection. LPA met with Executive Director and explained the purpose of the visit. Today's visit, LPA is conducting an annual inspection today but this report is being generated to clear the Post-Licensing inspection in the system. There are no citations issued on this report. Exit interview. Copy of report provided.the state’s words, verbatim · CDSS document, Jun 20, 2024

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Cassie Yang arrived unannounced at the facility to conduct a required annual inspection utilizing the full care tool. LPA met with Executive Director, Parvaneh Manouchehri, and explained the purpose of the visit. Today's census is 83 residents with nine residents on hospice services. Facility is licensed for 120 residents, hospice waiver of 15. During today's inspection, LPA and Executive Director conducted a tour the interior and exterior of the facility. Areas toured included but not limited to: courtyard, memory care unit bedrooms, assisted living unit bedrooms, bistro, main dining, private dining, kitchen, library, and the common areas. LPA observed care staff assisting residents with walking and other activities. LPA observed the facility to be clean, safe and in good repair. File review was conducted for 10 residents and 10 personnel files. LPA observed the files to be completed with the required documents. Inspection tool completed and found facility to be in substantial compliance. Executive Director and LPA discussed today is Executive Director's last day with this role as new director will start effective Monday. At this time, LPA is requesting facility liability insurance to be emailed to LPA by Friday June 28, 2024. No deficiencies observed during today's inspection. Exit interview conducted and a copy of report was provided.the state’s words, verbatim · CDSS document, Jun 20, 2024

Allegation investigated: Staff are not CPR trained.

On 2/29/2024, Licensing Program Analyst (LPA) Sarena Keosavang arrived at the facility unannounced to deliver investigation findings. LPA met with Executive Director (ED), Pari Manouchehri, and explained the purpose of the visit. Throughout the course of the investigation, the Department conducted interviews with facility staff, residents in care, and reviewed pertinent documentation relevant to the allegation listed above such as residents’ physician’s report, assessments, residents’ roster, staff roster, CRP certificate trainings, first aid trainings, and facility’s policy for review. Continue on page LIC9099-C. Unfounded According to the interview statement received, at least four (4) facility staff are not CPR trained. The Department conducted interviews and received statements from a total of five (5) facility staff. Interview statement received from staff (S1) indicated, the facility only provides Cardiopulmonary Resuscitation (CPR) trainings to Medication Technicians (Med Techs). CPR training is not provided to care providers. Med Techs are assigned to work per shift. All staff are trained in first aid. The Department requested and reviewed the facility’s policy for scheduling staff in CPR and first aid. The policy indicated, the schedule for direct care staff will include at least one staff member who is trained in CPR and first aid on each shift. The person responsible for developing and maintaining the schedule will keep a list of all staff members who have a current CPR and first aid card. When the schedule is produced, the person responsible for developing the schedule will check that at least one person scheduled for each shift in the community has a current CPR and First Aid card. One person certified in CPR and First Aid working in either Assisted Living or Traditions will be sufficient for this purpose. If an unexpected absence results in no trained staff member being in the community for the shift, and if attempts to obtain a trained staff member to substitute are unsuccessful, the problem will be referred to the Executive Director for resolution which may necessitate that a management team member who has CPE and First Aid certification cover as the trained staff member for the shift. The Department requested and reviewed a total of ten (10) facility staff CPR and First Aid certifications. The facility has two CPR training sessions scheduled for February and March of 2024. The Department interviewed and received statements from a total of seven (7) facility staff. Interview statement received from staff (S3) stated, Med Techs are required to be CPR certified to work at the facility. There is always one person who works in the community that is CPR certified either a Med Tech or staff. S3 stated the Department’s manager does the scheduling and they are aware who is CPR certified and would schedule them to work. Interview statement received from staff (S5) stated, was recently hired at the facility and is CPR certified. There is always a Med Tech on duty for each shift. If there is no Med Tech working at the facility due to call out or vacation the facility will find a replacement. If the facility is having a difficult time finding a replacement, then the Resident Care Coordinator will take over the position. Per Health and Safety Code, while CPR training is not required for all direct care staff, licensees must ensure there is at least one staff person who has CPR training to be on duty and on the premises of a facility at all times. The allegation is UNFOUNDED. A finding that the allegation is unfounded means that the allegation is false, could not have happened, and/or is without reasonable basis. No deficiencies are being cited during today’s visit. Exit interview conducted. Allegation: Staff did not ensure facility was free from pests. – Unsubstantiated. According to the interview statement received, there are cockroaches in the Memory Care Unit. There are rats running around the main entrance of the facility. A resident (R3) has lice and may have given other residents in care lice. The Department interviewed and received statements from a total of five (5) facility staff and one (1) residents in care. According to staff (S2), it was verified that R3 did have lice. R3 started lice treatment after staff discovered it. R3’s responsible party and primary care physician was notified. Interview statement received from staff (S1) indicated, all residents in the Traditions Memory Care Unit were checked by the Health Services Director to ensure lice was not spread to other residents in care. R3’s belongings were washed. Interview statement received from staff (S5) stated, observed dead cockroaches, two rats, and a baby snack at the facility on different occasions. Management was notified. There was a total of three (3) facility staff who observed the rats in the lobby. Interview statement received from resident indicated did not observe any pests at the facility. On 2/14/2024, LPA Keosavang arrived at the facility unannounced to commence complaint investigation. LPA toured the Memory Care unit and kitchen with staff (S1). LPA toured a total of five (5) residents’ bedrooms and bathrooms. LPA observed residents’ bedrooms and bathrooms to be clean, sanitary, and in good condition. All five (5) residents’ bedrooms and bathrooms were free of pests. Allegation: Staff do not change residents timely. – Unsubstantiated. According to an interview statement received, staff are letting residents in care sit in urine and feces resulting in bed sores. The Department requested three (3) resident’s physician’s report, admission agreement, assessments for review. According to resident’s (R3) physician's report, R3 is diagnosed with mild cognitive impairment. R3 cannot independently transfer to and from bed. R3 does not have a history of skin condition or breakdown. According to R3’s assessment, R3 requires complete assistance with toileting needs and has difficulty maintaining socially acceptable hygiene standards. R3 has fragile skin and needs skin checks up to 3 times a day. R3 has no healing wounds or bedsores. R3 requires checks 7-8 times each shift due to recent hospitalization, illness, medication change, etc. R3 requires services from hospice staff. Coordination of care provided by community nurse. The Department received interview statements from a total of five (5) facility staff and one (1) residents in care. Interview statement received from staff (S3) indicated that R3 is in hospice and is bed bound. R3 requires staff to reposition R3 and the pillow that is being used. Interview statement received from staff (S5) indicated that R3’s room is located the opposite side of the memory care’s common area and tends to be “forgotten”. S5 stated R3 has bed sores, and the hospice nurse changes the dressing on the bed sores. Staff are required to assist R3 with repositioning and shifting pillows between R2’s legs every hour. S5 had observed R3 left in soiled brief on the AM shift. S5 stated on 2-3 occasions the staff had to change R2’s bedding due to it being soaked through. Allegation: Staff smoke marijuana at the facility. – Unsubstantiated. According to interview statements received, the managers and kitchen staff were observed stepping outside by the employee parking lot to smoke marijuana before returning to work. The Department interviewed a total of five (5) facility staff and one (1) residents in care. Interview statement received from staff (S1) indicated that there is a designated area for staff to smoke cigarettes and vapes. Interview statement received from staff (S3) indicated that there are staff that smoke and vape but have never observed staff smoking or vaping in the community. S3 denied smoking in the community. Interview statement received from staff (S5) stated, “There are a couple of staff that smokes marijuana and comes back smelling like it.” S5 stated, had not observed the managers smoking marijuana. Interview statement received from resident indicated did not observe any staff smoking marijuana at the facility. Based on interview statements received, records review, and observations, the Department finds the above allegations to be UNSUBSTANTIATED, meaning that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. Exit interview conducted and a copy of report provided.the state’s words, verbatim · CDSS document, Feb 29, 2024 · control 59-AS-20240208162840