Inspection Reports for
Sierra Oaks Assisted Living & Memory Care

The inspection included tours of all three buildings and review of resident and staff files. No immediate health, safety, or personal rights violations were observed, and no deficiencies were cited as a result of the inspection.

The Licensing Program Analyst observed the four relocated residents, spoke with two of them and a responsible party of one resident, toured the resident rooms, and did not observe any deficiencies. No deficiencies were cited.

The complaint investigation was substantiated based on evidence from interviews, observations, and record reviews. Allegations included missed medications due to staff negligence, unsafe resident positioning due to lack of supervision, and neglect resulting in a resident being left in feces. The facility was cited under California Code of Regulations Title 22 for these deficiencies.

The investigation substantiated all allegations: medications were missed due to staff negligence and lack of supplies; a resident was found wedged between the bed and wall in an unsafe situation due to lack of supervision; and a resident was left soiled with feces for extended periods, with inadequate documentation and care. Multiple interviews, observations, and record reviews confirmed these deficiencies.

The complaint alleged insufficient staffing to meet residents' needs. The allegation was substantiated based on interviews, observations, and record reviews.

The investigation found that the facility did not have enough staffing to meet residents' needs, resulting in skipped showers, laundry, incomplete resident checks, and delayed care. The allegation was substantiated based on interviews, observations, and record reviews.

The allegation that the facility was understaffed causing residents to wait for assistance was investigated and found to be unsubstantiated.

The investigation found that staffing was adequate for the month of August 2025, with no instance of only one staff on duty. The allegation of understaffing and residents waiting more than an hour for assistance was unsubstantiated, with an average call light response time of 12 minutes. No deficiencies were cited.

The visit was triggered by a complaint/incident report sent by the facility on 2025-06-17 concerning resident R1's fractured right femur. The department is reviewing the case and will follow up as needed. No citations were issued per Title 22 Regulations.

The department reviewed the incident involving resident R1 who was found on the ground twice and later diagnosed with a fractured right femur. Interviews were conducted with the administrator and nurse director. No citations were issued at this time, and the case remains under review.

The facility was found to be in compliance with no deficiencies cited. The environment was clean, safe, and well-maintained, with all required equipment and supplies in place and operational.

The complaint was substantiated based on investigation observations, interviews, and record reviews. The allegation that staff were not mitigating the spread of scabies was confirmed.

The investigation found that staff were not effectively mitigating the spread of scabies, with approximately 15 residents and three staff developing rashes, and two residents plus a family member diagnosed with scabies. The facility failed to meet the requirement to provide safe, healthful, and comfortable accommodations, posing a potential risk to residents.

The complaint was substantiated. The incident involved a resident injury caused by another resident during a staff member's inappropriate behavior (shadow boxing). The staff member was terminated. The facility was cited for failure to protect the resident from injury under HSC 1569.2(c).

The investigation found that on 2023-10-19, a staff person was shadow boxing with one resident, which led to that resident hitting another resident causing an injury. The injured resident was treated at a hospital and returned to the facility. The staff person involved was terminated. The allegation was substantiated based on interviews, observations, and record reviews.

The complaint included allegations that staff did not report an incident to the responsible party, staff negligence causing resident injuries, failure to assist residents with medical care, failure to follow resident care plans, and failure to meet dietary needs. The allegation of failure to notify the responsible party was substantiated. Allegations of staff negligence and failure to assist with medical care were found unfounded. Allegations regarding care plan and dietary needs were unsubstantiated.

The investigation substantiated that staff failed to notify the responsible party of a resident's fall, citing a deficiency under CCR 87211(a)(1). Other allegations regarding staff negligence, failure to assist with medical care, and failure to meet dietary needs were found unsubstantiated or unproven due to insufficient evidence.

The complaint investigation was unsubstantiated for the allegation that facility staff were not properly trained. The allegation that the facility kitchen refrigerator door was in disrepair was found to be unfounded.

The investigation included interviews with the administrator, dietary director, and eight staff members, as well as document reviews and a facility walkthrough. The findings concluded that staff training was adequate and the refrigerator door was securely closed despite a malfunctioning secondary latch, which was being repaired. Both allegations were found to be unsubstantiated or unfounded.

The complaint alleged financial abuse due to failure to issue a refund within 30 days after the death of a resident and removal of personal property. The allegation was substantiated based on evidence that the refund of $5314.36 was not issued to Resident 1's responsible party as required.

The investigation substantiated that the licensee did not refund the prorated balance of fees within 30 days after the resident's death and removal of property, violating the admissions agreement. A deficiency was cited for failure to refund $5314.36 to the responsible party.

The facility was toured inside and out, including client rooms, bathrooms, and common areas. All areas were found to be properly equipped and maintained, with operational safety equipment and no deficiencies noted. The facility is ready to be licensed.