Inspection Reports for
Oakmont of Carmichael

The complaint alleged staff physically abused a resident. The investigation concluded the allegation was unfounded as the evidence did not support the claim.

The investigation found that the allegation was unfounded based on evidence and interviews. The resident with dementia exhibited combative behavior, and staff actions were appropriate during the incident.

The visit was triggered by a complaint regarding an incident on 2025-11-28 where a resident exhibited combative behavior towards staff during care. The report does not state substantiation status.

The report details an incident where a resident slapped and scratched a staff member while being assisted with morning care. The facility reported the incident to the resident's POA, Ombudsman, and Sheriff's Department and is conducting staff training on behavioral expressions, combative behaviors, and mandated reporting.

The complaint alleged that staff were disturbing residents' sleep. After investigation, the allegation was found to be unfounded, meaning it was false or without reasonable basis.

The investigation found that staff provide incontinent care on a schedule and as needed, including waking some residents for dressing and grooming before shift end. The Licensing Program Analyst did not find that staff were operating outside of residents' identified care needs, and the allegation was determined to be unfounded.

The visit was triggered by an incident report regarding medication errors. The complaint was investigated with interviews of all med techs and review of medication records. No deficiencies were cited.

The visit found that 9 residents had medications that were not bubble packed, and a medication error was observed involving 5 pills in a narcotic bottle that were a different medication. The facility has taken steps to require all medications to be bubble packed moving forward and will notify families of financial responsibility changes. No deficiencies were cited during this visit.

The inspection found the facility to be properly maintained with no deficiencies cited. Areas observed included bedrooms, bathrooms, kitchen, medication storage, and outdoor areas, all meeting regulatory standards.

The visit was triggered by an incident report concerning an unwitnessed fall of Resident R1 on 3/12/25. The resident was hospitalized and later returned to the facility on 3/18/25.

During the visit, no deficiencies were cited. The resident involved in the incident returned to the facility and is now receiving hospice care services. The Licensing Program Analyst will return once all requested documentation is received to complete the follow-up.

The facility was found to be in compliance with regulations, with properly maintained and sanitary living areas, adequate food supplies, and no safety hazards observed. No deficiencies were cited during this visit.

During the visit, resident and staff files were reviewed and medication storage was checked. No deficiencies were cited according to California Code of Regulations, Title 22.

The allegation was substantiated based on the evidence that physician's reports were out of date for three residents.

The inspection found that three of six residents had physician's reports that were out of date, resulting in a substantiated allegation and citation for noncompliance with Title 22 regulations related to care of persons with dementia.

The inspection found no immediate health, safety, or personal rights violations. Resident care needs appeared to be met, and no deficiencies were cited during this visit.

The follow-up inspection was conducted related to a prior complaint investigation #25-AS-20220519170123.

The inspection found that staff members (S1 and S2) had not completed the required initial medication shadowing training prior to administering medications, and staff (S3) had not completed the required continuing in-service medication training within the last 12 months, posing potential health and safety risks to residents.

The visit was related to complaint #25-AS-20211027124047, which was opened and closed under the prior license. Complaint findings were issued on April 12, 2022.

No deficiencies were issued during this inspection. However, a $500 penalty was issued for a violation from July 2018 that resulted in injury or illness to a resident.

The facility was observed to be clean, in good repair, odor free, and well stocked with necessary supplies. No deficiencies were observed during the inspection.

The visit was triggered by two incident reports: Resident 1 felt light-headed and was sent to the emergency room; Resident 2, diagnosed with dementia, was able to exit through a window but was found safely in the courtyard with minor skin tears. The administrator contacted the Licensing Program Analyst promptly after the incidents.

The facility acted promptly in response to incidents involving two residents, with no deficiencies issued during this unannounced inspection.

The visit was triggered by an open complaint. The Licensing Program Analyst arrived unannounced to continue the investigation. No deficiencies were found during this visit.

No deficiencies were issued during this inspection. The inspection included discussion of the current COVID-19 situation and a recent resident death, with the facility agreeing to provide a copy of the county death certificate to the Department when received.

The facility took appropriate actions following each incident, including emergency services and physician notifications. No deficiencies were found, but more complete documentation on incident reports was discussed.

The facility was found to be in substantial compliance with no immediate health, safety, or personal rights violations observed. No deficiencies were cited as a result of the inspection.

The facility was observed to be clean, in good repair, with sufficient furniture, lighting, food supplies, and safety equipment. No deficiencies were found during the inspection.