Inspection Reports for
Oakmont of Fair Oaks

The visit was related to substantiated complaint allegations totaling 23 since licensing; the follow-up meeting addressed compliance after these complaints.

The facility is maintaining ongoing compliance with open communication with the Department and receiving assistance from the Technical Support Program. Increased monitoring will continue as deemed necessary to ensure ongoing compliance.

The complaint investigation was substantiated for medication mismanagement, unsubstantiated for failure to provide assistance with ADLs, and unfounded for retaining residents beyond the level of care. The medication mismanagement involved discrepancies in medication counts and documentation for residents R1, R2, R3, and R4.

The investigation substantiated the allegation that facility staff mismanaged residents' medications, citing deficiencies related to medication administration. The allegation that staff were not providing assistance with ADLs was unsubstantiated. The allegation that the facility was retaining residents beyond a level of care they can provide was found to be unfounded.

The complaint investigation was substantiated regarding the facility's failure to address resident falls properly, specifically not calling 9-1-1 after falls with potential head injuries. Other allegations about cleanliness, catheter care, food services, and hygiene assistance were unsubstantiated.

The investigation substantiated that the facility failed to immediately call 9-1-1 after a resident sustained falls with potential head injuries on two occasions, posing an immediate health and safety risk. Other allegations regarding cleanliness, catheter assistance, food services, and hygiene assistance were found to be unsubstantiated based on interviews, observations, and record reviews.

The facility had repeat violations related to medication errors and medication management. The facility committed to enforcing quality assurance systems for medication management and ensuring staff competency through required training.

23 substantiated complaint allegations since licensing on July 27, 2021.

The facility had repeat violations related to medication errors and medication management. The facility committed to enforcing quality assurance systems for medication management and ensuring staff competency through required training.

The complaint was substantiated. The allegation was that staff were not adequately trained on emergency evacuation protocols following a fire on February 1, 2025. Interviews and documentation review confirmed inadequate training and incomplete evacuation during the fire.

The investigation substantiated the allegation that staff were not properly trained on emergency evacuation protocols. Interviews with staff revealed inadequate training and participation in drills. The fire was contained to the laundry room with no injuries, but some residents were not evacuated properly. The facility's Plan of Operation lacked specific training objectives and documentation did not comply with Title 22 regulations.

The facility was found to have an administrator without an active Administrator certificate, which poses potential health, safety, and personal rights risks to residents. A deficiency was cited and a plan of correction was required.

The complaint investigation was substantiated for the allegation that staff were not meeting a resident's oxygen needs while in care. Other allegations about a defective call button, inadequate care and supervision, and lack of planned activities were unsubstantiated.

The investigation substantiated the allegation that staff did not ensure a resident's oxygen needs were met according to physician's orders, posing an immediate health and safety risk. Other allegations regarding the defective call button, inadequate care and supervision, and lack of planned activities were found to be unsubstantiated based on interviews, observations, and record reviews.

The complaint was substantiated based on interviews, medication count, observation, and records review. The allegations involved medication administration errors and inadequate PPE provision to staff. Two civil penalties were assessed for repeat violations within 12 months.

The investigation substantiated that the facility failed to ensure resident R1 received medications as prescribed and that staff did not consistently wear full PPE when caring for residents in isolation due to COVID-19. Two civil penalties of $250 each were assessed for repeated violations.

The complaint was substantiated. The investigation included interviews, medication counts, and record reviews. A civil penalty of $250 was assessed for a repeat violation within 12 months.

The investigation found that resident R1 did not receive new medications as prescribed after hospital discharge, with medication delivery delays and discrepancies in medication counts. The allegation was substantiated, and a deficiency was cited for failure to assist residents with self-administered medications.

The complaint investigation was substantiated. Allegations included failure to meet residents' care needs, insufficient staffing, lack of oxygen signage, medication mismanagement, and inadequate staff training. Some allegations about food quality, visitation, and cleanliness were unsubstantiated.

The investigation substantiated several allegations including failure to provide adequate incontinence care and bathing assistance, insufficient staffing leading to delayed response times, lack of proper oxygen signage, medication mismanagement including inaccurate medication counts and improper approvals, and inadequate staff training hours. Some allegations regarding food quality, visitation, and facility cleanliness were found unsubstantiated.

The complaint was substantiated. The allegation was that the facility did not have adequate staffing to meet residents' needs, supported by interviews and call button response time records.

The investigation found the allegation substantiated based on staff interviews and review of call button response time records, which showed response times exceeding 15 minutes and up to 42 minutes, posing a potential health and safety risk to residents.

The Licensing Program Analyst observed that residents' care needs were being met, PPE supplies and staffing were sufficient, and infection prevention measures were generally adequate. However, a deficiency was cited for failure to report COVID-19 cases to the licensing agency within the required timeframe.

The Licensing Program Analyst observed that residents' care needs were being met, PPE supplies and staffing were sufficient, and infection prevention measures were generally adequate. However, a deficiency was cited for failure to report COVID-19 positive cases to the licensing agency within 24 hours as required by regulations.

The complaint was substantiated. Allegations included staff failing to respond to resident's call button, leaving resident unattended for hours after a fall, and untrained staff. The investigation found evidence supporting these allegations based on interviews, documentation review, and pendant response records. One allegation about a resident fall was unfounded.

The investigation substantiated allegations that staff failed to respond timely to a resident's call pendant on multiple occasions, leaving the resident unattended for extended periods, and that some staff lacked required initial or annual training. One allegation regarding a resident fall was found to be unfounded.