Inspection Reports for Oakmont Gardens
301 White Oak Dr, Santa Rosa, CA 95409, CA, 95409
Back to Facility ProfileInspection Report Summary
Most inspections found deficiencies related primarily to medication management, resident supervision, and facility safety, with several substantiated complaints about delayed staff responses to call buttons and medication errors. The facility was cited multiple times for medication errors caused by pre-pouring practices, unlocked medication storage, and failure to monitor residents at risk for elopement. Serious issues included resident elopements, prolonged delays in staff response to calls for assistance, and a water shutoff lasting over 24 hours without timely emergency measures; no fines or license suspensions were listed in the available reports. Several complaint investigations were unsubstantiated, indicating some allegations were not confirmed. The most recent report from September 4, 2025, still found multiple deficiencies including medication errors, unlocked medication rooms, and facility maintenance concerns, showing ongoing challenges despite corrective actions.
Deficiencies per Year
8
6
4
2
0
High
Moderate
Unclassified
Census Over Time
Census
Capacity
Inspection Report
Follow-Up
Capacity: 79
Deficiencies: 6
Sep 4, 2025
Visit Reason
Unannounced Case Management visit to follow up on previously cited deficiencies and plans of correction related to medication administration, personal rights training, and facility maintenance.
Findings
The inspection found ongoing deficiencies including medication room left unattended and unlocked with medications accessible to residents, pre-pouring of medications despite facility claims to have stopped, exposed walls with mildew odor posing health risks, and failure to document resident refusals of emergency medical services. Multiple Type A deficiencies were cited related to medication errors, resident rights, and facility safety.
Severity Breakdown
Type A: 6
Deficiencies (6)
| Description | Severity |
|---|---|
| Medication room unattended, unlocked, and medication bubble pack accessible to residents. | Type A |
| Staff pre-pouring medications resulting in medication errors. | Type A |
| Residents R1, R2, R3, R4, R5, R6, and R7 administered wrong medication. | Type A |
| Resident R1 waited over 33 minutes for staff response after activating pendant alert. | Type A |
| Centrally stored medications not kept in a safe and locked place accessible only to authorized employees. | Type A |
| Black and white fuzzy substance with mildew odor inside exposed walls in hallway by rooms #113-#116 posing health risk. | Type A |
Report Facts
Facility capacity: 79
Resident pendant alert wait time: 33
Number of residents administered wrong medication: 7
Plan of Correction due date: Sep 18, 2025
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Sanjay Kabadi | Administrator | Met with Licensing Program Analyst during inspection |
| Pam Brown | Health Services Assistant | Submitted required plans of correction for deficiencies |
| Jody Livingston | Health and Wellness Director | Interviewed regarding medication pre-pouring and facility compliance |
| Victoria Bertozzi | Licensing Program Manager | Named as Licensing Program Manager on report |
| Christi Coppo | Licensing Program Analyst | Conducted inspection and signed report |
Inspection Report
Complaint Investigation
Census: 62
Capacity: 79
Deficiencies: 2
Jul 17, 2025
Visit Reason
The visit was an unannounced Case Management visit triggered by incident reports received on 7/10/25 indicating medication errors affecting seven residents on 7/7/25 and a possible wrong medication administration to another resident on the same date.
Findings
The investigation found that medication errors occurred due to staff pre-pouring medications, resulting in seven residents receiving the wrong medications and one resident receiving medications late. The facility acknowledged ongoing issues with pre-pouring and has taken corrective actions including suspension of involved staff, planned additional training, staff meetings, audits, and elimination of pre-pouring medication boxes.
Complaint Details
The visit was complaint-related due to incident reports of medication errors affecting multiple residents. The facility was found to have substantiated medication errors caused by pre-pouring practices. Staff involved were disciplined, and corrective measures were planned and implemented.
Severity Breakdown
Type A: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Staff are pre-pouring medications, resulting in medication errors, which poses an immediate health, safety or personal rights risk to persons in care. | Type A |
| Residents R1, R2, R3, R4, R5, R6, and R7 were each administered the wrong medication, posing an immediate health, safety or personal rights risk to persons in care. | Type A |
Report Facts
Residents affected by medication error: 7
Medication pre-pouring instances: 2
Plan of Correction due date: Jul 18, 2025
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Tristan Amari | Business Office Manager | Met with Licensing Program Analyst during inspection |
| Jody Livingston | Health and Wellness Director | Interviewed about medication errors and corrective actions |
| Pam Brown | Health Services Assistant | Interviewed about medication errors and corrective actions |
Inspection Report
Complaint Investigation
Census: 61
Capacity: 79
Deficiencies: 1
Jul 17, 2025
Visit Reason
An unannounced complaint investigation was conducted due to allegations that staff did not respond to a resident's request for assistance in a timely manner.
Findings
The investigation found that resident R1 waited between 15 and 33 minutes for staff response after activating their pendant call, exceeding the facility's policy of responding within 10 minutes. The allegation was substantiated based on interviews and record reviews.
Complaint Details
The complaint alleged staff did not respond to resident's request for assistance in a timely manner. The allegation was substantiated based on evidence including pendant call logs and interviews. The facility was cited under California Code of Regulations, Title 22, Division 6, and the Health and Safety Code.
Severity Breakdown
Type A: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to provide care, supervision, and services that meet individual needs as evidenced by resident R1 waiting in excess of 33 minutes for staff response after activating pendant alert, posing an immediate health, safety, or personal rights risk. | Type A |
Report Facts
Resident wait times: 33
Census: 61
Total capacity: 79
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Tristan Amari | Business Office Manager | Met with during investigation and involved in exit interview |
| Christi Coppo | Licensing Program Analyst | Conducted the complaint investigation |
| Victoria Bertozzi | Licensing Program Manager | Named in report as Licensing Program Manager |
| Jody Livingston | Health and Wellness Director | Interviewed during investigation regarding prompt response standards |
| Pam Brown | Health Services Assistant | Interviewed during investigation regarding prompt response standards |
Inspection Report
Complaint Investigation
Capacity: 79
Deficiencies: 1
Jun 10, 2025
Visit Reason
An unannounced complaint investigation was conducted due to allegations that the facility water was turned off, resulting in residents not being provided drinking water or water for toilets and bathing.
Findings
The investigation substantiated the complaint that the facility water was shut off for more than 24 hours without immediately providing for residents' needs such as bathing and flushing toilets, posing an immediate health, safety, and personal rights risk. The facility did not notify the licensing agency of the water shut off and failed to fully engage their emergency disaster plan initially. Water service was restored on 5/12/25 at 8:30pm after delivery of bottled water, port-a-potties, and other interim measures.
Complaint Details
Complaint was substantiated. The facility water was turned off starting 5/11/25 and remained off for more than 24 hours. The facility did not notify the licensing agency as required and failed to fully implement their emergency disaster plan initially. Interim measures such as bottled water delivery and port-a-potties were provided. Water was restored on 5/12/25 at 8:30pm. The licensing analyst conducted a health and wellness check on 5/13/25 and found water fully operational.
Severity Breakdown
Type A: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Facility water shut off for more than 24 hours without immediately providing for residents needs that require access to running water like bathing and flushing toilets, posing an immediate health, safety or personal rights risk to persons in care. | Type A |
Report Facts
Facility capacity: 79
Deficiency count: 1
Plan of Correction due date: Jun 11, 2025
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Tristan Amari | Business Office Manager | Met with during investigation and communicated about water shut off and interim measures |
| Mark Strohschein | Administrator | Contacted by Licensing Program Analyst regarding water shut off and emergency disaster plan |
| Christi Coppo | Licensing Program Analyst | Conducted the complaint investigation and health and wellness check |
| Victoria Bertozzi | Licensing Program Manager | Oversaw licensing program and signed report |
Inspection Report
Complaint Investigation
Capacity: 79
Deficiencies: 1
Jun 10, 2025
Visit Reason
The visit was an unannounced Case Management visit triggered by an incident report received on 2025-05-14 regarding resident R1 eloping from the facility and being found alone outside the facility property.
Findings
The facility was found to have failed to meet the requirement to have an auditory device or staff alert feature to monitor exits accessible to residents at risk for elopement, as evidenced by resident R1 eloping and being found outside the facility. The facility provided 1:1 care for R1 after the incident until the resident was no longer at the facility.
Complaint Details
The visit was complaint-related due to an incident report of resident R1 eloping from the facility and being found alone outside the facility property. The complaint was substantiated as the facility was found deficient in monitoring exits for residents at risk of elopement.
Severity Breakdown
Type A: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to ensure the facility has an auditory device or other staff alert feature to monitor exits on exterior doors and perimeter fence gates accessible to residents at risk for elopement. | Type A |
Report Facts
Capacity: 79
Plan of Correction Due Date: Jun 11, 2025
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Tristan Amari | Business Office Manager | Met with Licensing Program Analyst during the visit and discussed findings |
| Christi Coppo | Licensing Program Analyst | Conducted the unannounced Case Management visit and authored the report |
| Victoria Bertozzi | Licensing Program Manager | Named in the report as Licensing Program Manager |
| Jody Livingston | Health and Wellness Director | Provided information about resident R1's care and Wander Guard device |
Inspection Report
Capacity: 79
Deficiencies: 0
May 13, 2025
Visit Reason
The visit was an unannounced case management health check conducted to verify the status of water functionality at the facility following a reported water pipe break and water shutoff incident.
Findings
The water was found to be fully functional at the time of inspection with all resident toilets working and access to water restored. No citations were issued during this visit, but the facility was reminded to report any incidents posing health and safety risks to residents within 24 hours as required by regulation.
Report Facts
Facility capacity: 79
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jody Livingston | Health and Wellness Director | Met with Licensing Program Analyst during the health check visit |
| Christi Coppo | Licensing Program Analyst | Conducted the unannounced health and wellness check |
| Morgan Holien | Administrator/Director | Facility Administrator named in the report header |
| Tristan Amari | Business Office Manager | Provided email communication regarding water repair status |
Inspection Report
Complaint Investigation
Capacity: 79
Deficiencies: 0
Feb 7, 2025
Visit Reason
The visit was an unannounced Case Management - Incident inspection following an incident report submitted by the facility regarding a resident found on the floor with injuries and subsequent hospitalization and death.
Findings
The Licensing Program Analyst conducted the visit but was unable to clarify the cause of death as key staff were unavailable. The facility was requested to submit resident documents by February 10, 2025. No deficiencies were cited during this visit.
Complaint Details
The visit was triggered by an incident report for resident R1 who was found on the floor with injuries and later passed away. The cause of death was unknown at the time of the visit. The Licensing Program Analyst was unable to obtain further clarification due to unavailability of the Administrator and Health and Wellness Director.
Report Facts
Facility capacity: 79
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Morgan Holien | Facility Administrator | Not available at time of visit; related to incident report |
| Jody Livingston | Health and Wellness Director | Not available at time of visit; related to incident report |
| Christi Coppo | Licensing Program Analyst | Conducted the unannounced Case Management visit |
| Gloria Albor | Business Operations Manager | Met with Licensing Program Analyst during visit; did not have access to resident documents |
Inspection Report
Annual Inspection
Census: 47
Capacity: 79
Deficiencies: 4
Jan 14, 2025
Visit Reason
The inspection was an unannounced required annual inspection conducted to evaluate compliance with licensing regulations for the facility.
Findings
The facility was generally found to be clean and well-maintained with appropriate food storage and safety measures. However, several deficiencies were cited related to unlocked storage of disinfectants, incomplete staff training hours, missing fingerprint clearances for two staff members, and lack of required CPR/First Aid certification for some staff.
Deficiencies (4)
| Description |
|---|
| Disinfectants and cleaning solutions were observed in an unlocked cabinet in the ancillary Assisted Living Dining room. |
| Five out of five staff reviewed did not have the required hours of training completed. |
| Four out of five staff did not have 1st Aid/CPR on file. |
| Two staff members did not have fingerprint clearance on file and were not associated with the facility. |
Report Facts
Resident records reviewed: 6
Staff records reviewed: 5
Staff without fingerprint clearance: 2
Staff without required training hours: 5
Staff without 1st Aid/CPR on file: 4
Inspection Report
Complaint Investigation
Capacity: 79
Deficiencies: 0
Nov 7, 2024
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by an allegation that the facility was not maintained in a safe condition for residents, specifically regarding cracked and raised sidewalk concrete presenting safety hazards.
Findings
The investigation found that while the sidewalk concrete was cracked and raised, presenting a potential safety hazard, the facility had taken steps to mitigate risks by shaving down the concrete, posting warning signs, and actively seeking bids for repairs. The allegation was determined to be unsubstantiated due to lack of preponderance of evidence.
Complaint Details
The complaint alleged unsafe conditions due to cracked and raised sidewalk concrete at two locations. The allegation was unsubstantiated after investigation. The facility was aware of the issue, had been working on obtaining bids and permits for repairs, and had taken interim safety measures. The complaint control number is 21-AS-20241031093432.
Report Facts
Facility capacity: 79
Complaint control number: 21-AS-20241031093432
Permit processing time estimate: 4
Permit processing time estimate: 6
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Morgan Holien | Administrator | Met with Licensing Program Analyst during investigation and provided information about sidewalk repairs |
| Christi Coppo | Licensing Program Analyst | Conducted the complaint investigation visit |
| Victoria Bertozzi | Licensing Program Manager | Named as Licensing Program Manager on report |
Inspection Report
Complaint Investigation
Capacity: 79
Deficiencies: 1
Aug 9, 2024
Visit Reason
The visit was a case management inspection conducted in response to an incident report submitted on 2024-07-19 regarding a medication error at the facility.
Findings
The investigation confirmed a medication error involving a resident receiving PRN Tramadol and scheduled Gabapentin without proper medication technician oversight. The resident did not exhibit adverse reactions. The facility terminated the involved staff, adjusted medication technician scheduling to cover all shifts, conducted staff training on medication administration policies, and is redesigning the medication room to improve safety.
Complaint Details
The visit was triggered by a complaint/incident report of a medication error submitted on 2024-07-19. The medication error was substantiated as the facility confirmed the incident and took corrective actions including staff termination and policy changes.
Severity Breakdown
Type A: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| The licensee failed to assist residents with self-administered medications as needed, resulting in a medication error posing an immediate health, safety, or personal rights risk. | Type A |
Report Facts
Facility capacity: 79
Plan of Correction due date: Aug 19, 2024
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Christi Coppo | Licensing Program Analyst | Conducted the case management visit and authored the report |
| Victoria Bertozzi | Licensing Program Manager | Supervisor overseeing the licensing evaluation |
| Morgan Holien | Administrator | Facility administrator named in the report header |
| Jody Livingston | Health and Wellness Director | Facility staff involved in notification and corrective actions related to the medication error |
Inspection Report
Complaint Investigation
Census: 41
Capacity: 79
Deficiencies: 0
May 9, 2024
Visit Reason
The inspection was conducted as a case management visit following a report of physical abuse involving a resident who reported being touched under the covers while sleeping.
Findings
The facility conducted an internal investigation which yielded a finding of unsubstantiated abuse. The resident is now on frequent checks to monitor mental health and overall comfort. No deficiencies were cited during this inspection.
Complaint Details
The complaint involved a report of physical abuse by a resident who did not identify the suspected abuser. The facility reported the incident to police and LTCO. The police conducted a telephone interview with the resident. The facility's investigation found the abuse unsubstantiated.
Report Facts
Capacity: 79
Census: 41
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Morgan Holien | Administrator | Met with Licensing Program Analyst and involved in investigation |
| Christi Coppo | Licensing Program Analyst | Conducted the case management visit |
| Victoria Bertozzi | Licensing Program Manager | Named in report header |
Inspection Report
Capacity: 79
Deficiencies: 0
Mar 1, 2024
Visit Reason
An informal office meeting was conducted to discuss the facility's ongoing lack of a qualified Administrator and the plan for the Executive Director to complete Administrator Certification.
Findings
No deficiencies were cited. The facility agreed to submit proof of Administrator Certification completion and a written plan outlining the duties of the Executive Director and Acting Administrator.
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Ryan Exline | Director of Operations | Met with licensing staff during the informal office meeting. |
| Morgan Holien | Executive Director | Met with licensing staff and agreed to complete Administrator Certification. |
| Victoria Bertozzi | Licensing Program Manager | Participated in the meeting and is named as Licensing Program Manager. |
| Christi Coppo | Licensing Program Analyst | Participated in the meeting and is named as Licensing Program Analyst. |
Inspection Report
Annual Inspection
Census: 45
Capacity: 79
Deficiencies: 5
Jan 18, 2024
Visit Reason
The inspection visit was an unannounced continuation of the required annual inspection for regulatory compliance and case management oversight at the facility.
Findings
The inspection identified multiple deficiencies including failure to assist residents with self-administered medications, incomplete staff training documentation, improper medication storage practices, lack of a hospice care plan for a resident on hospice, and outdated medical assessment for a resident with dementia.
Severity Breakdown
Type A: 1
Type B: 4
Deficiencies (5)
| Description | Severity |
|---|---|
| Resident R2 missed two doses of Acetaminophen 325mg, Amlodipine 2.5 mg, and Furosemide 20 mg; doses were documented as given but were not administered. | Type A |
| Five out of five staff files were missing training logs or did not show the number of training hours completed. | Type B |
| Medications were pre-poured and not stored in their originally received containers as required. | Type B |
| Resident on hospice (R1) did not have a hospice care plan on file at the time of initial inspection. | Type B |
| Resident R4 with dementia had an outdated medical assessment from 2021 and lacked an annual reassessment. | Type B |
Report Facts
Civil penalty amount: 600
Residents reviewed: 5
Staff files reviewed: 5
Missed medication doses: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Christi Coppo | Licensing Program Analyst | Conducted the inspection and cited deficiencies |
| Bethany Moellers | Licensing Program Manager | Supervisor overseeing the inspection |
| Morgan Holien | Executive Director | Facility representative during inspection and exit interview |
Inspection Report
Annual Inspection
Census: 45
Capacity: 79
Deficiencies: 3
Jan 11, 2024
Visit Reason
An unannounced Required - 1 Year annual inspection was conducted to evaluate compliance with licensing regulations at Oakmont Gardens Assisted Living facility.
Findings
The inspection found two deficiencies posing immediate health and safety risks: the facility lacked a qualified and currently certified administrator, and toxins were stored in an unlocked cabinet accessible to residents. Additionally, the facility retained a resident with dementia without a current exception on file.
Severity Breakdown
Type A: 2
Type B: 1
Deficiencies (3)
| Description | Severity |
|---|---|
| Facility does not have a qualified and currently certified administrator, posing an immediate health, safety or personal rights risk to residents. | Type A |
| Toxins stored in an unlocked cabinet in the ancillary Assisted Living Dining Area, accessible to residents, posing an immediate health, safety or personal rights risk. | Type A |
| Facility retained a resident with dementia without a current exception on file, posing a potential health, safety or personal rights risk. | Type B |
Report Facts
Census: 45
Total Capacity: 79
Plan of Correction Due Date: Jan 12, 2024
Plan of Correction Due Date: Jan 29, 2024
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Morgan Holien | Executive Director | Interviewed during inspection; named in deficiency related to administrator certification |
| Christi Coppo | Licensing Program Analyst | Conducted the inspection and authored the report |
| Bethany Moellers | Licensing Program Manager | Supervisor overseeing the inspection |
Inspection Report
Complaint Investigation
Census: 46
Capacity: 79
Deficiencies: 2
Dec 19, 2023
Visit Reason
The inspection was an unannounced complaint investigation triggered by allegations that staff mismanaged a resident's medication and did not seek timely medical attention following a fall, as well as allegations that staff did not respond to call bells timely and failed to meet reporting requirements.
Findings
The investigation found insufficient evidence to substantiate the medication mismanagement and delayed medical attention allegations, but substantiated that staff responses to call bells were often delayed and that the facility failed to provide required written incident reports to the resident's responsible person. Deficiencies related to personnel sufficiency and reporting requirements were cited.
Complaint Details
The complaint investigation was initiated based on allegations that staff mismanaged resident R1's medications and failed to provide timely medical attention after a fall on 10/31/2023. Additional allegations included failure to respond timely to call bells and failure to meet reporting requirements. The medication and medical attention allegations were unsubstantiated, but the call bell response delays and reporting failures were substantiated.
Severity Breakdown
Type A: 1
Type B: 1
Deficiencies (2)
| Description | Severity |
|---|---|
| Personnel Requirements. Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs. Based upon review of call log records, out of 22 responses for calls to R1’s room in October 2023, six exceeded 25 minutes and one was 126 minutes. This posed an immediate risk to the health and safety of residents in care. | Type A |
| Reporting Requirements. A written report shall be submitted to the person responsible for the resident within seven days of the occurrence of any specified events. R1’s Responsible Person states no copy of the Incident Report for 10/31 was received and the report does not indicate a copy was provided. This posed a potential risk to the personal rights of R1. | Type B |
Report Facts
Responses to call bells: 22
Delayed responses over 25 minutes: 6
Delayed response duration: 126
Deficiency Type A due date: Dec 19, 2023
Deficiency Type B due date: Jan 2, 2024
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| David Leibert | Licensing Program Analyst | Conducted the complaint investigation and delivered findings |
| Carla Martinez | Licensing Program Manager | Oversaw the complaint investigation |
Inspection Report
Complaint Investigation
Census: 42
Capacity: 79
Deficiencies: 1
Dec 12, 2023
Visit Reason
The inspection was an unannounced complaint investigation triggered by an allegation that staff did not respond to a resident's call button in a timely manner.
Findings
The investigation found that staff failed to respond timely to a resident's call button after a fall, with at least one incident showing a 94-minute delay. The allegation was substantiated based on the preponderance of evidence.
Complaint Details
The complaint alleged that staff did not respond to a resident's call button in a timely manner after the resident fell. The allegation was substantiated.
Severity Breakdown
Type A: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Personnel Requirements – General Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs. Facility did not meet this requirement as staff did not respond to a resident's call button in a timely manner. | Type A |
Report Facts
Delay time: 94
Deficiencies cited: 1
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Christi Coppo | Licensing Program Analyst | Conducted the complaint investigation and signed the report |
| Bethany Moellers | Licensing Program Manager | Oversaw the complaint investigation and signed the report |
| Morgan Holien | Executive Director | Facility representative met during the investigation |
Inspection Report
Census: 46
Capacity: 79
Deficiencies: 0
Dec 12, 2023
Visit Reason
Unannounced case management visit to follow up on the facility's current lack of a certified Administrator.
Findings
No deficiencies were cited. The Executive Director and Licensing staff discussed the proposed Administrator and additional documentation needed, with a follow-up planned.
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Morgan Holien | Executive Director | Met during the visit and discussed proposed Administrator and documentation needed. |
| Christi Coppo | Licensing Program Analyst | Conducted the case management visit. |
| Victoria Bertozzi | Licensing Program Manager | Conducted the case management visit. |
Inspection Report
Complaint Investigation
Census: 50
Capacity: 79
Deficiencies: 3
Nov 3, 2023
Visit Reason
The visit was an unannounced case management inspection regarding an incident report received on 10/24/2023 involving a resident who eloped from the facility and sustained injuries.
Findings
The investigation found that the resident left the facility unassisted during a period when caregivers were canceled without notifying staff, resulting in the resident's elopement and injury. The facility lacked a qualified and certified administrator, and the Executive Director did not have required fingerprint clearance. The facility updated the resident's care plan to include hourly checks to monitor wandering behavior.
Complaint Details
The visit was triggered by a complaint incident report regarding a resident (R1) who eloped from the facility on 10/22/2023 and was found with bruises and a scraped leg. The complaint was substantiated by findings of inadequate supervision and administrative deficiencies.
Severity Breakdown
Type A: 3
Deficiencies (3)
| Description | Severity |
|---|---|
| Executive Director does not have fingerprint clearance as required by regulation. | Type A |
| Facility personnel were insufficient in numbers and competence, evidenced by resident elopement posing immediate health and safety risk. | Type A |
| Facility does not have a currently qualified and certified administrator, posing immediate health and safety risk. | Type A |
Report Facts
Capacity: 79
Census: 50
Plan of Correction Due Date: POC due date is 11/06/2023 for all cited deficiencies
Hourly checks frequency: 4
Hourly checks frequency: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Morgan Holien | Executive Director | Named in findings related to lack of fingerprint clearance and facility administration |
| Jody Livingston | Health and Wellness Director | Provided information on resident care and intake evaluation |
| Christi Coppo | Licensing Program Analyst | Conducted the inspection and authored the report |
| Bethany Moellers | Licensing Program Manager | Supervisor overseeing the inspection |
Inspection Report
Complaint Investigation
Census: 46
Capacity: 79
Deficiencies: 0
Jul 31, 2023
Visit Reason
The visit was an unannounced complaint investigation conducted in response to a complaint received on 2023-05-19 alleging inadequate resident care including leaving a resident in soiled clothing, improper toileting assistance, call buttons not within reach, and untimely repositioning.
Findings
The investigation found the allegations unsubstantiated due to inconsistent statements and lack of corroborating evidence. Interviews with residents, staff, and outside agencies did not confirm the complaints, and observations indicated timely and appropriate resident care.
Complaint Details
The complaint was unsubstantiated. Allegations included residents left in soiled clothing, improper toileting assistance, call buttons not within reach, and untimely repositioning. The Licensing Program Analyst could not prove or disprove the allegations due to inconsistent statements and lack of evidence.
Report Facts
Complaint Control Number: 21-AS-20230519161049
Capacity: 79
Census: 46
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Farhaan Sarangi | Licensing Program Analyst | Conducted the complaint investigation and delivered findings |
| Morgan Holien | Administrator | Met with Licensing Program Analyst during investigation |
| Hope DeBenedetti | Licensing Program Manager | Named in report as Licensing Program Manager |
Inspection Report
Complaint Investigation
Census: 46
Capacity: 79
Deficiencies: 1
Jul 31, 2023
Visit Reason
The Licensing Program Analyst conducted an unannounced Case Management-Deficiency Inspection at Oakmont Gardens to investigate a complaint regarding missing resident documentation.
Findings
The inspection found that Resident #1 was missing the most recent LIC 602/Physician Assessment, which the facility failed to retain. This deficiency poses a potential health, safety, and personal rights risk to residents.
Complaint Details
The visit was complaint-related, investigating missing resident records. The deficiency was substantiated as the facility did not retain the required updated LIC 602 for Resident #1.
Severity Breakdown
Type B: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Resident #1 was missing the most recent LIC 602/Physician Assessment due to the facility not retaining the updated LIC 602. | Type B |
Report Facts
Deficiency due date: Aug 7, 2023
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Farhaan Sarangi | Licensing Program Analyst | Conducted the complaint investigation and inspection |
| Morgan Holien | Administrator | Met with Licensing Program Analyst during inspection |
| Hope DeBenedetti | Licensing Program Manager | Named as Licensing Program Manager overseeing the inspection |
Inspection Report
Complaint Investigation
Census: 46
Capacity: 79
Deficiencies: 0
Jul 6, 2023
Visit Reason
The inspection was an unannounced complaint investigation visit conducted in response to allegations received on 2023-06-14 regarding staff not ensuring residents' dignity, residents being left in soiled clothing for extended periods, and staff refusing to provide assistance to residents.
Findings
The investigation found no preponderance of evidence to prove or disprove the allegations. Interviews with residents and staff, as well as observations during the facility tour, did not reveal any concerns or evidence supporting the complaints. Therefore, all allegations were determined to be unsubstantiated.
Complaint Details
The complaint investigation was unsubstantiated, meaning the allegations could not be proven or disproven based on the evidence gathered. The specific allegations included staff not ensuring residents' dignity, residents left in soiled clothing for extended periods, and staff refusing to provide assistance to residents.
Report Facts
Facility capacity: 79
Resident census: 46
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Farhaan Sarangi | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Morgan Holien | Administrator | Met with the Licensing Program Analyst during the inspection |
| Hope DeBenedetti | Licensing Program Manager | Named as Licensing Program Manager on the report |
Inspection Report
Complaint Investigation
Census: 46
Capacity: 79
Deficiencies: 0
Jul 6, 2023
Visit Reason
The inspection visit was an unannounced complaint investigation triggered by an allegation that facility staff did not ensure that passageways were kept free of obstruction.
Findings
The complaint allegation that passageways were obstructed was found to be unsubstantiated due to lack of preponderance of evidence. A new ramp was installed recently and Resident #1 was content with its placement.
Complaint Details
The complaint was unsubstantiated, meaning there was insufficient evidence to prove the alleged violation occurred. The allegation was that facility staff did not keep passageways free of obstruction.
Report Facts
Complaint Control Number: 21-AS-20230525101426
Facility Capacity: 79
Census: 46
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Farhaan Sarangi | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Morgan Holien | Administrator | Met with the Licensing Program Analyst during the investigation |
| Jody Livingston | Director of Health and Wellness | Received the exit interview and report copy |
| Hope DeBenedetti | Licensing Program Manager | Named as Licensing Program Manager on the report |
Inspection Report
Complaint Investigation
Census: 41
Capacity: 79
Deficiencies: 0
Jan 20, 2023
Visit Reason
An unannounced complaint investigation was conducted in response to multiple allegations received on 10/12/2022 regarding specialized diets, designated substitute availability, medication administration, emergency plan effectiveness, and resident room adequacy.
Findings
All complaint allegations were found to be unsubstantiated or unfounded due to insufficient evidence or prior investigation results. No deficiencies were cited during the inspection.
Complaint Details
The complaint investigation addressed allegations that the facility was not following specialized diets, lacked a designated substitute qualified to act in the administrator's absence, failed to administer medication according to physician orders, did not have an effective emergency plan, and that a resident's room did not meet their needs. All allegations were determined unsubstantiated or unfounded after review of records, interviews, and prior investigations.
Report Facts
Capacity: 79
Census: 41
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Marisol Cuadra | Licensing Program Analyst | Conducted the complaint investigation and delivered findings |
| Morgan Holien | Executive Director | Met with Licensing Program Analyst during investigation |
| Mariele Soriano | Administrator | Facility administrator named in report |
Inspection Report
Annual Inspection
Census: 41
Capacity: 79
Deficiencies: 0
Jan 20, 2023
Visit Reason
The inspection was an unannounced annual required inspection focused on infection control procedures and practices at the facility.
Findings
The facility was found to be compliant with infection control practices, including COVID-19 screening, PPE supply, and documentation. No deficiencies were cited during this inspection.
Report Facts
PPE supply duration: 30
Medication supply duration: 30
Document update deadline: Jan 27, 2023
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Morgan Holien | Executive Director | Met with Licensing Program Analyst during inspection and agreed to submit document updates. |
| Jody Livingston | Health Services Director | Met with Licensing Program Analyst during inspection. |
Inspection Report
Census: 43
Capacity: 79
Deficiencies: 0
Sep 13, 2022
Visit Reason
The visit was conducted for the purpose of amending the D page of the 9099(A) form that was created on 2022-09-08.
Findings
The licensing program analyst returned to the facility to amend a previously created document; no other findings or deficiencies are noted in the report.
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| David Leibert | Licensing Program Analyst | Returned to facility to amend the D page of the 9099(A) form. |
| Carla Martinez | Licensing Program Manager | Named as Licensing Program Manager on the report. |
Inspection Report
Complaint Investigation
Census: 131
Capacity: 79
Deficiencies: 2
Sep 8, 2022
Visit Reason
The inspection was an unannounced complaint investigation visit conducted to investigate allegations that staff failed to meet residents' care needs and mismanaged a resident's medication.
Findings
The investigation found the first set of allegations regarding failure to meet care needs unsubstantiated due to insufficient evidence. However, the medication mismanagement allegations were substantiated, confirming that a resident was administered discontinued medications resulting in hospitalization. Deficiencies were cited and corrective actions were implemented.
Complaint Details
The complaint investigation was triggered by allegations that staff failed to meet residents' care needs and mismanaged a resident's medication. The medication mismanagement was substantiated, confirming that a resident was administered discontinued medications causing hospitalization. The care needs allegations were unsubstantiated.
Severity Breakdown
Type A: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| R1 was given medications that had been ordered discontinued by physician, posing an immediate risk to the health of R1. | Type A |
| Failure to provide care and supervision including assistance with taking medications as required, evidenced by R1 being given discontinued medications. | Type A |
Report Facts
Capacity: 79
Census: 131
Deficiencies cited: 2
Plan of Correction Due Date: Sep 8, 2022
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| David Leibert | Licensing Program Analyst | Conducted the complaint investigation and delivered findings |
| Mariele Soriano | Administrator | Facility administrator named in the report |
| Carla Martinez | Licensing Program Manager | Named as Licensing Program Manager overseeing the investigation |
Inspection Report
Complaint Investigation
Census: 116
Capacity: 79
Deficiencies: 0
Jul 19, 2022
Visit Reason
The inspection was an unannounced complaint investigation triggered by allegations received on 2022-06-29 regarding staff response times and accessibility issues in resident rooms.
Findings
The investigation found that pendant call response times averaged 5 minutes and 11 seconds, the complainant's wheelchair could be maneuvered through the bathroom doors, and accommodations met Title Twenty-Two regulations. The allegations were determined to be unfounded and dismissed with no citations issued.
Complaint Details
The complaint alleged that staff did not assist residents timely and that the resident's room did not meet their needs, specifically regarding bathroom accessibility. The complaint was investigated through interviews, record reviews, and site visits and was found to be without reasonable basis and unfounded.
Report Facts
Pendant call response time: 311
Census: 116
Total capacity: 79
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| David Leibert | Evaluator / Licensing Program Analyst | Conducted the complaint investigation and delivered findings |
| Morgan Holien | Facility representative met during investigation |
Inspection Report
Original Licensing
Census: 41
Capacity: 79
Deficiencies: 0
Jun 10, 2022
Visit Reason
The inspection was an unannounced Post Licensing visit conducted to evaluate the facility's compliance following initial licensing.
Findings
The facility was found to be clean, well-maintained, and in good repair with no deficiencies observed. Staff and residents were vaccinated and boosted for COVID-19, infection control plans were discussed, and safety measures such as locked medication storage and fire safety equipment were in place.
Report Facts
Facility capacity: 79
Resident census: 41
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Erik Gonzalez Campos | Licensing Program Analyst | Conducted the Post Licensing Inspection |
| Morgan Holien | Executive Director | Met with Licensing Program Analyst during inspection |
| Katelyn Ledesma | Health/Wellness Director | Met with Licensing Program Analyst during inspection and participated in exit interview |
Inspection Report
Follow-Up
Census: 41
Capacity: 79
Deficiencies: 0
Jun 10, 2022
Visit Reason
This inspection was a follow-up to two SOC341s received by Community Care Licensing on 05/10/2022 and 05/20/2022, conducted as a Case Management - Incident visit.
Findings
No deficiencies were observed during the inspection. Interviews were conducted with the Executive Director and Health/Wellness Director, and records were reviewed.
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Erik Gonzalez Campos | Licensing Program Analyst | Conducted the Case Management Inspection and authored the report. |
| Morgan Holien | Executive Director | Met with Licensing Program Analyst during the inspection. |
| Katelyn Ledesma | Health/Wellness Director | Met with Licensing Program Analyst during the inspection. |
Inspection Report
Census: 40
Capacity: 79
Deficiencies: 0
Mar 3, 2022
Visit Reason
Licensing Program Analyst Erik Gonzalez Campos conducted an unannounced case management inspection as a follow-up to a SOC341 received by community care licensing on 2022-02-08.
Findings
The Licensing Program Analyst reviewed resident files and assisted living resident and services agreements, discussed the facility administrator transition, and requested several licensing documents during the visit.
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Erik Gonzalez Campos | Licensing Program Analyst | Conducted the case management inspection. |
| Katelyn Ledesma | Health and Wellness Director | Met with Licensing Program Analyst during the inspection. |
| Mariele Soriano | Administrator | Current administrator discussed during the inspection. |
| Morgan Holein | Executive Director | Discussed as the incoming administrator. |
Inspection Report
Original Licensing
Census: 45
Capacity: 79
Deficiencies: 0
Jan 26, 2022
Visit Reason
The inspection was conducted as a pre-licensing visit to evaluate the facility for licensing approval.
Findings
The facility was toured and found to have required furnishings and safety features in resident rooms, sufficient first aid supplies, locked medication and cleaning supply storage, and compliance with food storage regulations. The facility received an approved fire clearance allowing for 69 non-ambulatory and 10 bedridden residents.
Report Facts
Fire clearance capacity: 69
Fire clearance capacity: 10
Assisted living apartments: 56
Independent living apartments: 107
Water temperature: 109.8
Water temperature: 114.3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Erik Gonzalez-Campos | Licensing Program Analyst | Conducted the pre-licensing inspection |
| Melinda Ward | Interim Administrator | Met with Licensing Program Analyst during inspection |
| Mariele Soriano | Administrator | Current administrator who agreed to inspection |
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