Inspection Reports for Oakmont of East Sacramento

An unannounced case management visit was conducted to gather additional information and facility documentation related to a SOC 341 report concerning sexually inappropriate behavior by a resident.

The visit found that a safety plan was implemented to address the behavior of the resident involved, who has since moved out of the facility. No deficiencies were cited during the inspection.

The complaint involved Resident 1 engaging in sexually inappropriate behavior with another resident, as observed by the resident's wife. The facility implemented a safety plan and coordinated with the resident's responsible party. Resident 1 has moved out of the facility.

The visit was an unannounced complaint investigation conducted in response to allegations received on 2025-07-28 regarding inadequate incontinent care, uncomfortable meal conditions, and lack of dignity and respect in resident care.

The investigation included interviews with staff, residents, family members, and direct observations. No evidence was found to substantiate the allegations. Residents' incontinent care needs were met, mealtimes were comfortable, and residents were treated with dignity and respect. No deficiencies were cited.

The complaint allegations were found to be unsubstantiated after investigation. The preponderance of evidence standard was not met to prove the alleged violations occurred.

The inspection was an unannounced annual inspection conducted to evaluate the facility's compliance with licensing requirements and ensure the health and safety of residents.

The facility was found to be clean, in good repair, and in compliance with Title 22 regulations. Observations included sufficient food supplies, proper medication storage, and safety measures such as smoke detectors and fire extinguishers. Resident and staff files were complete, and staff background checks were verified.

The visit was an unannounced complaint investigation conducted in response to allegations that staff did not keep the facility free from bug infestation and did not ensure a resident had sufficient clothing.

The investigation found that the facility responded promptly to bed bug reports by hiring pest control companies and treating affected areas, and provided clothing and hygiene items to residents when necessary. Based on the evidence gathered, the allegations were found to be unsubstantiated.

The complaint investigation was unsubstantiated, meaning there was not a preponderance of evidence to prove the alleged violations occurred regarding bug infestation and insufficient resident clothing.

The visit was an unannounced complaint investigation conducted in response to a complaint received on 2024-04-25 regarding allegations of inadequate resident care including assistance with showers, blood glucose testing equipment maintenance, and timely medication reordering.

The investigation found insufficient evidence to substantiate the allegations. Facility records, staff and resident interviews indicated that the resident in question was generally independent in personal care and medication management. The allegations were determined to be unsubstantiated due to lack of preponderance of evidence.

The complaint involved three allegations: 1) staff not assisting a resident with showers, 2) staff not ensuring the resident's blood glucose testing equipment was working properly, and 3) staff not ensuring residents' medication was reordered timely causing missed medication. The findings were unsubstantiated as evidence did not prove the alleged violations occurred.

The visit was an unannounced case management follow-up on an incident report received by the department on 2024-06-29 regarding a resident's medication administration and wound care.

The facility failed to report a resident's unstageable wound within the required 7 days and did not administer prescribed medication to the resident for a total of 12 days, posing potential health, safety, and personal rights risks.

The visit was an unannounced complaint investigation conducted to address allegations that staff did not respond to residents' call pendants in a timely manner and did not ensure residents' oxygen care needs were met in a timely manner.

The investigation substantiated the allegation that staff did not respond to residents' call pendants in a timely manner, with 7 out of 8 SMART care log alerts not responded to within 15 minutes, posing potential health and safety risks. The allegation regarding oxygen care needs was unsubstantiated as evidence showed residents on oxygen received appropriate monitoring and assistance.

The complaint investigation was substantiated for the allegation that staff did not respond to residents' call pendants in a timely manner. The allegation that staff did not ensure residents' oxygen care needs were met in a timely manner was unsubstantiated.

The inspection visit was conducted as an unannounced complaint investigation following a complaint received on 2024-04-19 regarding allegations that staff did not safeguard resident’s personal belongings, did not assist resident with feeding, and did not meet resident's needs.

The investigation found that the allegations were unsubstantiated due to lack of preponderance of evidence. It was noted that resident 1's glasses were broken and discarded by staff without informing the resident or Power of Attorney, but reimbursement was provided. Resident 1 was able to feed independently and did not require assistance as per the individualized service plan and physician's report.

The complaint involved allegations that staff did not safeguard resident’s personal belongings, did not assist resident with feeding, and did not meet resident's needs. The investigation included interviews with staff and residents and review of records. The allegations were found to be unsubstantiated.

The visit was an unannounced complaint investigation conducted in response to a complaint received on 2024-05-08 alleging that the facility did not prevent a resident from making inappropriate comments to other residents.

The investigation included interviews with 9 residents and 5 staff members, all of whom denied witnessing or making inappropriate comments. The facility's staff house rules prohibit disruptive or abusive behavior. The allegations were found to be unsubstantiated due to lack of sufficient evidence.

The complaint alleged that the facility did not prevent a resident from making inappropriate comments to other residents. After investigation, the allegations were found to be unsubstantiated as there was not a preponderance of evidence to prove the violation occurred.

The visit was an unannounced annual inspection conducted to evaluate the health and safety compliance of the facility.

The facility was found to be clean, in good repair, and compliant with regulations including fire safety, medication storage, and resident care. No deficiencies were cited during the inspection.

An unannounced case management inspection was conducted to address concerns discovered during an unrelated complaint investigation.

No deficiencies were cited per California Code of Regulations, TITLE 22. The case management inspection was not completed due to time constraints and will be continued at a later date.

The visit was an unannounced case management inspection conducted in response to concerns brought to the department's attention on 10/30/2023 regarding the facility's failure to provide timely written responses to family council concerns.

The facility was found deficient for not providing written responses within 14 calendar days to family council concerns submitted on 09/09/2023 and 10/10/2023, with only a verbal response provided on 11/14/2023. Deficiencies were cited under California Code of Regulations, Title 22, and California Health and Safety Code.

The visit was an unannounced Plan of Correction (POC) follow-up to verify correction of prior deficiencies and plans of correction due on 11/07/2023 from a complaint investigation conducted on 10/24/2023.

The deficiency cited under Title 22 Regulation 87303(i)(1)(B) was cleared during this visit. Although the facility did not comply by the original POC due date, the administrator provided POC documents during the visit. Civil penalties were assessed for failure to correct by the due date, accruing $100 per day until correction.

The visit followed a complaint investigation conducted on 10/24/2023. The POC was due on 11/07/2023. Civil penalties were assessed for failure to correct the cited deficiency by the due date.

The inspection visit was an unannounced complaint investigation conducted in response to an allegation that staff do not respond to resident(s) call bells in a timely manner.

The investigation substantiated the allegation that staff did not respond to residents' call bells in a timely manner. Review of Personal Health Button Reports revealed that 3 out of 10 residents' calls were not responded to within 15 minutes, and 7 residents reported that calls were never responded to, posing a potential health, safety, or personal rights risk.

The complaint was substantiated. The allegation was that staff do not respond to resident call bells in a timely manner. The investigation included interviews with staff, residents, and review of records. It was found that response times exceeded 15 minutes for some residents and some calls were never responded to.

The visit was an unannounced complaint investigation conducted to address allegations regarding staff not providing a resident with a copy of financial statements and inadequately keeping records regarding a resident's expenses.

The investigation found the allegation that staff did not provide a resident with a copy of financial statements to be unsubstantiated, but substantiated that staff did not adequately keep records regarding a resident's expenses, specifically failing to provide a monthly itemized statement of charges. A deficiency was cited related to this issue with a plan of correction due.

The complaint investigation was triggered by allegations that staff were not providing a resident with a copy of financial statements and were not adequately keeping records regarding a resident's expenses. The allegation regarding financial statements was unsubstantiated, while the allegation regarding record keeping was substantiated.

An unannounced complaint investigation was conducted in response to allegations received on 07/28/2023 regarding staff stealing and fraudulently using residents' credit cards and failure to adhere to reporting requirements.

The investigation substantiated the allegations of personal rights violations involving four instances of credit card theft and unauthorized use by a staff member who was arrested. The facility failed to meet all mandated reporting requirements, specifically in submitting a suspected dependent adult/elder abuse report to the local ombudsperson within two working days. Another allegation regarding failure to follow theft/loss policy was found to be unfounded.

The complaint was substantiated for allegations of personal rights violations involving theft and fraudulent use of residents' credit cards by a staff member, and failure to adhere to mandated reporting requirements. The staff member was arrested and charged with 12 felony counts. The allegation regarding failure to follow theft/loss policy was unfounded.

The inspection was an unannounced complaint investigation visit conducted in response to a complaint alleging that the licensee does not ensure the facility is in good repair.

The investigation found that one of the facility's elevators was out of service from August 1, 2023, and was repaired on August 11, 2023, after a delayed replacement part shipment. The facility implemented meal tray service and transportation assistance during the elevator outage. Due to lack of preponderance of evidence, the allegation was unsubstantiated.

The complaint was unsubstantiated as the facility addressed the elevator issue in a timely manner and there was insufficient evidence to prove the alleged violation occurred.

An unannounced complaint investigation was conducted in response to allegations including suspicious death and failure to call 911 during a medical emergency at Oakmont of East Sacramento.

The investigation found that the allegations could not be substantiated. The resident had a seizure-like episode and expired at the facility with a do not resuscitate order. Staff contacted Alpha One for medical transport, which is certified to provide emergency services, rather than 911. No deficiencies were cited.

The complaint involved allegations of suspicious death and failure to call 911 during a medical emergency. The allegations were determined to be unsubstantiated/unfounded based on interviews, record reviews, and evidence gathered during the investigation.

The inspection was an unannounced complaint investigation visit conducted to investigate allegations that facility staff were not ensuring resident receives showers, not cleaning resident's room, and not providing food following dietary restrictions, as well as a separate allegation regarding improper billing of a resident.

The investigation found the first set of allegations regarding showering assistance, room cleanliness, and dietary restrictions unsubstantiated based on resident statements and records. However, the allegation of improper billing related to a pet fee was substantiated, with the facility crediting the resident for the erroneous charge. No other deficiencies were noted.

The complaint investigation was triggered by allegations received on 2023-01-26 regarding failure to provide showers, room cleaning, and dietary compliance. These were unsubstantiated. A separate allegation of improper billing was substantiated, involving a pet fee charged inappropriately to a resident.

The inspection was conducted as a required 1 year annual inspection to evaluate the facility's compliance with health and safety regulations.

The facility was found to be clean, odor-free, and in good repair with all required safety equipment and supplies in place. No deficiencies were cited during the inspection.

The inspection was an unannounced complaint investigation visit conducted in response to complaints received on 2023-01-06 regarding staff not meeting with responsible party for reappraisal meeting, not showering a resident, and not meeting a resident's dietary needs.

The investigation found the allegations that staff did not meet with the responsible party for a reappraisal meeting and did not shower the resident to be unfounded. The allegation that staff did not meet the resident's dietary needs was unsubstantiated due to lack of preponderance of evidence.

The complaint investigation was based on three allegations: staff did not meet with responsible party for reappraisal meeting, staff do not shower resident, and staff do not meet resident's dietary needs. The first two allegations were found to be unfounded, and the third was unsubstantiated.

An unannounced complaint investigation visit was conducted in response to an allegation that facility staff did not provide adequate food service for residents.

Based on interviews and record review, it was determined that the resident received insulin and meals at appropriate times and the facility provided three snacks throughout the day. The allegations were unsubstantiated due to lack of preponderance of evidence.

The complaint alleged inadequate food service for residents. The investigation found no sufficient evidence to substantiate the allegation, resulting in an unsubstantiated finding.

An unannounced complaint investigation visit was conducted in response to an allegation that staff did not seek medical attention for a resident in care.

The investigation found that staff were never made aware of the resident having chest pain; chart notes indicated only shoulder pain treated with PRN medication. There was insufficient evidence to substantiate the allegation, so it was deemed unsubstantiated.

The complaint allegation was that staff did not seek medical attention for a resident in care. The allegation was unsubstantiated due to lack of preponderance of evidence.

The inspection was an unannounced complaint investigation visit conducted in response to multiple allegations received on 2022-11-07 regarding resident safety, staffing adequacy, hazard accessibility, dietary needs, and staff behavior.

The investigation found that most allegations were unsubstantiated, including concerns about elopement prevention, staffing adequacy, hazard accessibility, and dietary needs. However, the allegation that staff spoke inappropriately to residents was substantiated, with corrective actions initiated.

The complaint investigation was triggered by allegations including failure to prevent elopement of memory care residents, inadequate staffing, accessible hazards, unmet dietary needs, and inappropriate staff speech. The allegation of inappropriate speech by Staff 1 was substantiated; others were unsubstantiated.

The inspection was an unannounced complaint investigation visit conducted in response to allegations received on 2022-11-02 regarding a non-functioning call system and staff not following up with a resident's physician after emergency treatment.

The investigation found that the call system was functioning properly with staff responding timely to calls, and staff were regularly checking on the resident despite the resident's request to reduce checks. The allegations were determined to be unfounded.

The complaint investigation was conducted for two allegations: 1) Facility has a non-functioning call system, and 2) Staff did not follow-up with resident’s physician following emergency treatment. Both allegations were found to be unfounded.

An unannounced complaint investigation visit was conducted in response to allegations that staff allowed residents to perform tasks such as giving medications, opening mail, bathing, catheter changes, and dressing other residents.

The investigation found all allegations to be unfounded, determining that the residents were either independent in these activities or the allegations were false and without reasonable basis.

The complaint investigation was triggered by multiple allegations regarding improper resident care activities being performed by other residents. The findings concluded the allegations were unfounded.

The inspection was an unannounced Pre-Licensing inspection due to Change of Ownership.

The facility was found to be clean, odor-free, and in good repair with all required safety and health measures in place. No deficiencies were observed during the inspection.

report_22_342701121_inx21_2024-03-20.pdf