Inspection Reports for
Oakmont of Riverpark

The inspection focused on the physical plant and surrounding grounds, including memory care and assisted living units. The facility was found to have no health or safety hazards, with properly functioning fire extinguishers, alarms, clean and well-maintained common areas, bedrooms, restrooms, and kitchen. No citations were issued.

The complaint alleged that staff did not issue a refund to the resident's authorized representative in a timely manner. The allegation was substantiated based on interviews, record reviews, and evidence that the refund was delayed beyond the required timeframe.

The investigation substantiated that the facility did not issue the refund within the required 15 days after the resident's belongings were vacated. The refund was delayed due to extensive damage repairs and third-party vendor involvement, with the refund check received on 12/27/2025, exceeding both the regulatory and facility handbook timelines.

The complaint alleged that staff did not provide the authorized representative a refund after the resident passed away. The allegation was investigated through interviews, file reviews, and correspondence. Despite some concerns, there was insufficient evidence to substantiate the allegation, and it was deemed unsubstantiated.

The investigation included interviews, record reviews, and correspondence. It was found that the resident expired on 2025-09-07, with belongings remaining in the facility until 2025-10-05. The community fee refund was recalculated and a refund check was issued. However, there was insufficient evidence to prove the alleged violation, and the complaint was deemed unsubstantiated.

The facility was found to be in compliance with Title 22 regulations with no citations issued. The inspection included a physical plant tour, review of personnel and resident records, medication audit, infection control and emergency disaster planning review, staff and resident interviews, and review of maintenance and safety systems.

The facility was found to be generally compliant with regulations, with no immediate health or safety hazards observed. The physical plant, resident bedrooms, restrooms, kitchen, and records were all in order. Fire extinguishers were charged and alarms functioned properly. The facility serves residents with dementia and includes memory care and assisted living units.

The complaint investigation was triggered by allegations that staff did not ensure adequate food service or adherence to residents' diets, and did not answer a resident's call button. The food service allegations were unsubstantiated, but the call button allegation was substantiated based on pendant call records showing 10 out of 125 calls were not responded to, with 9 calls announced but no staff response documented.

The investigation found the food service allegations unsubstantiated due to insufficient evidence, but substantiated that staff failed to respond to a resident's call button in a timely manner, posing a potential health and safety risk. A deficiency was cited related to staff not responding to calls for assistance.

The complaint investigation was substantiated for the allegation that facility staff failed to provide hospital with POA contact information, but unsubstantiated for failure to contact POA regarding medical emergency. The investigation included interviews with the Executive Director, staff, and Resident 1's POA, as well as file reviews. The incorrect POA information on resident forms was a key factor in the substantiated finding.

The allegation that facility staff failed to provide the hospital with POA contact information was substantiated due to incorrect POA information on resident forms, posing a potential health and safety risk. The allegation that staff failed to contact POA regarding the medical emergency was unsubstantiated as the POA was notified after the resident was admitted to the hospital. A deficiency was cited for failure to maintain accurate resident records.

The complaint involved allegations that staff did not meet residents' medical needs and failed to refill medications timely. After review of records, interviews with staff and residents, and observations, the allegations were found to be unsubstantiated.

The investigation found that Resident 1 was receiving medical care and assistance despite some refusals of care and appointments by the resident. Medication refill concerns were unsubstantiated as staff submitted refills on time and residents reported no issues with medication availability. Overall, the allegations were deemed unsubstantiated.

The complaint investigation was substantiated for the allegation that staff did not ensure the resident's bathroom was clean. Other allegations including isolation of the resident, provision of toiletry supplies, hygiene care, and safeguarding personal belongings were unsubstantiated. The investigation included interviews with staff, the Executive Director, and review of documents and resident observations.

The investigation substantiated the allegation that staff did not ensure the resident's bathroom was clean, evidenced by observed dry feces and unsanitary conditions. Other allegations regarding isolation, toiletry supplies, hygiene, and safeguarding personal belongings were deemed unsubstantiated due to insufficient evidence.

The visit was triggered by a complaint related to a self-reported death of a resident following a fall and hospitalization. Substantiation status is not stated.

The Licensing Program Analyst conducted interviews with the Executive Director, Health Service Director, and one resident, toured the facility, and obtained pertinent documents. Further investigation is required prior to issuing findings.

The visit was triggered by complaint control number 29-AS-20231121093226. Six out of ten staff in the Traditions Memory care unit voiced concerns about resident treatment, including ignoring residents and yelling. Concerns were reported to management but not addressed.

Interviews with staff revealed concerns about the treatment of residents in the Traditions Memory care unit, including ignoring residents, yelling, and arguing with residents. Six out of ten staff reported observing such behaviors, which pose an immediate personal rights risk to residents.

The facility was found to be in compliance with Title 22 regulations with no citations issued. Fire safety equipment was properly maintained, emergency drills were conducted quarterly, and required postings were observed. Personnel and resident records were reviewed and found to be in order.

The facility was found to be in compliance with Title 22 regulations with no citations issued. The physical plant, kitchen, resident bedrooms, restrooms, common areas, and surrounding grounds were all observed to be clean, safe, and properly maintained. Infection control practices and emergency disaster plans were adequate. Medication audit revealed no errors.

The inspection found that the facility was generally compliant with health and safety regulations, including fire safety and infection control. However, deficiencies were noted related to the storage of disinfectants and cleaning solutions accessible to residents in locked rooms, and one staff member lacking a criminal record clearance. These issues posed immediate health and safety risks but were addressed during the visit.

The complaint investigation was unsubstantiated. Allegations included staff causing injury to Resident #1 by pulling their arm and choking them, and staff yelling at residents. Interviews, record reviews, and observations did not provide sufficient evidence to support these claims. Resident #1 was diagnosed with shoulder pain but no fracture or dislocation. Staff admitted to pressing their body against Resident #1 during showering to prevent hitting and scratching, which was deemed a personal rights violation.

The investigation found insufficient evidence to substantiate the allegations that staff caused injury to a resident or yelled at residents. However, a personal rights violation was noted due to staff pressing their body against a resident during care, and a Case Management report will address this deficiency.

The complaint was substantiated. It alleged neglect/lack of supervision causing Resident #1 to fall and sustain a fractured right shoulder. The investigation included interviews, medical record reviews, and incident report analysis. The allegation was supported by evidence and deemed substantiated.

The investigation substantiated the allegation that facility staff failed to provide appropriate supervision, resulting in Resident #1 falling and sustaining a fractured right humerus and bruising to the right eye. The fall occurred when Resident #1 ambulated without their walker and left the activity room undetected by staff.

The complaint alleged that the facility was not making the disaster plan available to residents. After investigation including interviews, document review, and observations, the allegation was unsubstantiated.

The investigation found that the Emergency Disaster Manual was available at the concierge desk and residents were aware of and had practiced the emergency disaster protocol. Staff had mixed awareness, but documentation of emergency disaster training was provided. The allegation was deemed unsubstantiated due to insufficient evidence of a violation.

The complaint was substantiated. Resident #1 sustained a fractured right wrist after a fall from bed due to staff neglecting the resident's wishes to get out of bed. The resident was a known fall risk with multiple prior falls. The facility failed to use fall prevention measures consistently, including failure to place a fall mat and non-use of a bed alarm. The motion sensor pagers were misplaced for about a year, reducing fall alert effectiveness.

The investigation substantiated that the facility failed to implement all fall precautions for Resident #1, resulting in a fall from bed and a fractured right wrist. The facility did not place the fall mat as instructed, and the bed alarm was not used because it was considered a restraint. The facility's motion sensor pagers were misplaced for about a year, rendering fall alerts ineffective. A $500 immediate civil penalty was assessed.

The facility was found generally compliant with Title 22 regulations, including kitchen, dining, and common areas. Infection control practices were adequate with proper PPE and symptom screening. However, deficiencies were cited related to water temperature exceeding regulatory limits and a staff member's fingerprint clearance not being associated with the facility.

The complaint was substantiated. It was found that staff violated residents' personal rights by waking Memory Care residents early without consent, confirmed through interviews and record review.

The investigation substantiated the allegation that staff were waking Memory Care residents beginning at 4:00 AM without specified consent, which violates residents' personal rights. Staff and resident interviews, along with record reviews, confirmed this practice and the difficulty residents have with being woken early.

The complaint was substantiated based on observations during the unannounced visit. The allegation was that the facility did not have contact information for the Ombudsman posted in the memory care unit.

The investigation found that the facility did not have an Ombudsman poster displayed in the memory care unit where residents could see it, although a poster was present in the assisted living activity room. This deficiency was substantiated and cited as a violation of CCR 87468.2(a)(10).

The inspection found multiple deficiencies including accessible medications and toxic substances to residents, and lack of documentation for quarterly disaster drills for each shift. A civil penalty of $250.00 was issued.

The visit was complaint-related due to an incident where resident #1 eloped from the facility on 11/19/2021. The complaint was substantiated as staff failed to supervise the resident.

The investigation found that staff failed to supervise resident #1, who left the facility unassisted, posing an immediate health and safety risk. Additionally, laundry detergent was found accessible to residents, which is a violation of care standards for persons with dementia.

The facility was found to have adequate linen, water, and nonperishable food supplies. Resident rooms and common areas were appropriately furnished and equipped. Fire safety equipment and systems were tested and found operable. One item, a current First Aid manual, was noted as needing to be submitted prior to licensing.