Inspection Reports for Oakmont of El Dorado Hills

The visit was an informal office meeting held on 10/22/2025 to discuss complaint history, including a complaint dated 09/25/2024, and to review updated fall protocols for residents identified as fall risks.

No deficiencies were cited during the visit. The facility representatives discussed their fall mitigation program, current fall risk assessments, resident-centered interventions, and policies for residents who suffer multiple falls.

The visit included discussion of a complaint dated 09/25/2024. No deficiencies were cited, indicating no substantiated violations.

The inspection was an unannounced complaint investigation visit triggered by an allegation that the facility was malodorous.

The investigation found the facility to be clean, sanitary, and free from odor during multiple tours and staff interviews. The allegation of the facility being malodorous was determined to be unfounded.

The complaint alleged that the facility was malodorous. After investigation including interviews and observations, the allegation was found to be unfounded.

The inspection was an unannounced complaint investigation visit conducted in response to allegations received on 2025-08-06 regarding medication administration, staffing levels, facility cleanliness, laundry machine condition, and call pendant functionality.

The investigation found the medication administration allegation unsubstantiated with no evidence of errors. Allegations of understaffing, non-working call pendants, unsanitary conditions, and laundry machine disrepair were found to be unfounded based on staff and resident interviews and observations, confirming the facility was adequately staffed, clean, and equipment functional.

The complaint investigation was unsubstantiated for medication errors and unfounded for understaffing, call pendant issues, cleanliness, and laundry machine disrepair. The findings were based on interviews with ten staff and five residents, document reviews, and observations.

The inspection was an unannounced complaint investigation visit conducted in response to multiple allegations received on 2025-05-02 regarding staff response to call buttons, resident movement, hot water delivery, and mail delivery.

The investigation found the allegation that staff were not responding to call buttons timely to be unsubstantiated, with typical response times ranging from 5 to 15 minutes. Other allegations regarding restricting resident movement, hot water delivery, and mail interference were found to be unfounded based on interviews, observations, and record reviews.

The complaint investigation was unsubstantiated for the call button response allegation and unfounded for the allegations regarding resident movement, hot water delivery, and mail interference. The report states that there was insufficient evidence to support these allegations.

The inspection was an unannounced complaint investigation visit triggered by a complaint received on 2025-05-27 regarding staff not ensuring the facility door is properly operating.

The investigation found that the activation button for wheelchair accessible residents did not always catch, but the door still opened automatically when pushed. Residents were not locked outside, and other doors were functioning properly. The allegations were found to be unsubstantiated due to lack of preponderance of evidence.

The complaint was unsubstantiated, meaning there was not sufficient evidence to prove the alleged violation occurred.

The inspection was an unannounced complaint investigation visit conducted in response to an allegation that staff were not following universal precautions to prevent the spread of scabies.

The investigation found that the facility was following universal precautions, including placing PPE outside the resident room at the first sign of a rash, notifying staff, and conducting in-service training on handwashing and precautions. The allegation was determined to be unfounded.

The complaint alleged that staff were not following universal precautions to ensure staff do not spread scabies. The allegation was found to be unfounded based on observation, record review, and statements.

The inspection was conducted as a required annual unannounced visit to evaluate compliance with licensing requirements.

The facility was found to be clean, well organized, and compliant with all health and safety regulations. No health or safety violations were observed during the tour of the facility and review of resident and staff files.

The inspection was an unannounced complaint investigation visit triggered by a complaint received on 2025-04-04 regarding allegations of staff mishandling a resident's medication and inappropriate staff behavior.

The investigation found insufficient evidence to substantiate the allegations of medication errors and inappropriate staff behavior. Interviews with staff and residents indicated no concerns, and the complaint was determined to be unsubstantiated or unfounded.

The complaint involved allegations that staff mishandled a resident's medication and made inappropriate comments or exhibited behavior posing risks to residents. The findings concluded the medication error allegation was unsubstantiated and the behavior allegation was unfounded.

The visit was an unannounced complaint investigation conducted in response to allegations including questionable death, insufficient staffing, and failure to seek timely medical attention for a resident.

The investigation found all allegations to be unfounded. Documentation and interviews confirmed the resident's death was natural and timely medical attention was provided. Staffing levels were adequate to meet residents' needs.

The complaint involved allegations of questionable death, insufficient staffing, and failure to seek timely medical attention. The investigation concluded all allegations were unfounded, meaning they were false or without reasonable basis.

The inspection was an unannounced complaint investigation visit conducted in response to multiple allegations received on 2025-03-19 regarding staff response times, resident pendant disrepair, facility conditions, communication with resident representatives, and meal service timeliness.

The investigation found all allegations to be unsubstantiated or unfounded. Staff response times to resident call buttons were timely, resident pendant systems were operable, the facility was clean and sanitary, staff properly followed universal precautions, and residents were provided meals in a timely manner.

The complaint investigation was unsubstantiated for allegations including staff not attending to residents timely and resident pendants in disrepair. Additional allegations of facility malodor, bathroom disrepair, failure to inform resident representatives of incidents, and untimely meal provision were found unfounded.

The inspection was an unannounced complaint investigation visit triggered by allegations received on 2024-09-25 regarding inadequate supervision and fall prevention resulting in resident injury.

The investigation substantiated that staff failed to provide adequate supervision and prevent multiple falls for resident R1, resulting in a serious injury including a fractured clavicle. The facility failed to develop and implement a personalized intervention plan and did not ensure staff training on fall prevention protocols. One allegation regarding failure to issue a refund was found to be unfounded.

The complaint was substantiated regarding inadequate supervision and fall prevention leading to resident injury. The allegation about failure to issue a refund was unfounded.

An unannounced complaint investigation visit was conducted to investigate multiple allegations received on 2025-02-10 regarding resident call pendant operability, staff response times, facility temperature, cleanliness, food service protocols, mail delivery, and a questionable death.

The investigation found all allegations to be unsubstantiated or unfounded. Residents and staff interviews, facility observations, and record reviews confirmed that call pendant systems were operable, staff responded timely, the facility was clean and odor free, food service was adequate and sanitary, mail was delivered properly, and the questionable death was consistent with hospice care and properly handled.

The complaint investigation was unsubstantiated or unfounded for all allegations including call pendant system operability, staff response times, facility temperature, cleanliness, food service, mail delivery, and questionable death. The complaint control number is 59-AS-20250210105545.

The inspection was an unannounced complaint investigation triggered by an allegation that residents contracted an illness of unknown origin while in care.

The investigation found that the facility experienced a stomach bug/flu outbreak lasting 24-48 hours, not an unknown illness. The facility followed universal precautions, conducted staff in-service on handwashing, encouraged residents to stay in their rooms, and managed symptomatic staff appropriately. The allegation was determined to be unfounded.

The complaint alleged residents contracted illness of unknown origin. The investigation found the allegation to be unfounded based on interviews with eight staff and six residents, document review, and observation of infection control measures.

An unannounced complaint investigation visit was conducted in response to allegations of staff financially abusing a resident and not ensuring residents were properly fed.

The investigation found no evidence of financial abuse by staff and confirmed that residents were properly fed with adequate food supply and meal provision. Both allegations were determined to be unfounded.

The complaint investigation was triggered by allegations of financial abuse and improper feeding of residents. After interviews with eight staff and six residents and document review, the allegations were found to be unfounded.

The inspection was an unannounced complaint investigation visit triggered by allegations of medication errors and staff not following universal precautions.

The investigation found the medication error allegation unsubstantiated due to insufficient evidence and proper medication administration documentation. The allegation regarding staff not following universal precautions was found to be unfounded, with evidence showing proper infection control measures and staff compliance.

The complaint investigation was unsubstantiated for medication errors, meaning there was not enough evidence to prove the alleged violation occurred. The allegation regarding universal precautions was unfounded, indicating the allegation was false or without reasonable basis.

The inspection was an unannounced complaint investigation visit triggered by allegations that staff were not ensuring residents' hygiene needs were met and that the facility was not sanitary.

The investigation found both allegations to be unfounded. Staff interviews and resident interviews confirmed that hygiene needs and toileting assistance were adequately provided, and the facility was observed to be clean and sanitary with no issues noted.

The complaint alleged that staff were not ensuring residents' hygiene needs were met and that the facility was not sanitary. After interviews with eight staff and six residents, and observations by the department, both allegations were found to be unfounded.

The inspection was an unannounced complaint investigation visit triggered by an allegation of staff mismanaging a resident's medication.

The investigation found insufficient evidence to substantiate the allegation of medication errors. Documentation and interviews with staff and residents indicated that medications were administered and logged correctly, and no concerns were reported.

The complaint was unsubstantiated, meaning there was not a preponderance of evidence to prove the alleged violation occurred.

The inspection was an unannounced complaint investigation visit triggered by allegations received on 2024-09-17 regarding facility maintenance, odor, and adequacy of resident care and supervision.

The investigation found the allegations to be unfounded based on staff and resident interviews and department observations, concluding the facility was clean, odor-free, and residents received adequate care and supervision.

The complaint included allegations that staff did not properly maintain the facility, did not keep the facility free from odor, and did not provide adequate care and supervision to a resident. The investigation determined all allegations to be unfounded.

The inspection was an unannounced complaint investigation visit conducted in response to allegations received on 2024-10-03 regarding cleanliness, food service adequacy, and COVID precaution adherence at the facility.

The investigation found all allegations to be unfounded after interviews with staff and residents, observations, and document reviews. The facility was observed to be clean and sanitary, food service was adequate and nutritious, and COVID precautions were properly followed.

The complaint included allegations that staff did not keep the facility clean or sanitary, did not provide adequate food service, and were not following precautions to mitigate the spread of COVID. All allegations were found to be unfounded.

The inspection was an unannounced complaint investigation visit triggered by an allegation that staff were not preventing a resident from being abused by another resident while in care.

The investigation found that the residents involved are independent and do not want interference in their personal lives. Staff and residents reported no physical violence or abuse, and the allegation was determined to be unfounded.

The complaint alleged that staff were not preventing a resident from being abused by another resident. The allegation was found to be unfounded based on interviews and documentation reviewed.

An unannounced complaint investigation was conducted in response to an allegation that staff were financially abusing residents.

The investigation found the allegation to be unfounded after interviews with staff and residents and review of documentation. It was determined that the Resident Council, not staff, organizes a voluntary surprise fund for front-line workers during the winter holidays.

The allegation of financial abuse by staff was investigated and found to be unfounded based on interviews and documentation.

The inspection was an unannounced complaint investigation visit conducted in response to allegations received on 2024-06-03 regarding staff sleeping during evening hours, leaving residents soiled, and leaving residents unattended.

The investigation found all allegations to be unfounded. Although one staff member was sleeping during the evening shift, sufficient awake staff were present as required by regulation. Care plans were followed, and staff provided appropriate assistance to residents, including toileting every two hours or as needed.

The complaint allegations included staff sleeping during evening hours, leaving residents soiled, and leaving residents unattended. All allegations were determined to be unfounded based on interviews and record reviews.

The visit was an unannounced required annual inspection conducted to evaluate compliance with regulatory standards and ensure the health and safety of residents.

The facility was found to be clean, well organized, and compliant with all required paperwork, staff training, fire drills, and safety measures. No health or safety violations were observed during the inspection.

The visit was an unannounced case management inspection following up on an incident report regarding a resident choking during dinner on 2024-05-18.

The department reviewed the incident where staff performed the Heimlich maneuver and chest compressions on the resident, who subsequently passed away. All requested documents were received, and no citations were issued per Title 22 Regulations.

The visit was triggered by an incident report of a resident choking and subsequent death. The case is under review and no citations were issued at this time.

The inspection was an unannounced complaint investigation visit triggered by allegations received on 2023-11-14 regarding staff response to residents' call buttons, nighttime supervision, and toileting needs.

The investigation found no evidence to substantiate the allegations. Staff were observed and interviewed, and records reviewed, showing timely response to call buttons, adequate nighttime supervision, and appropriate assistance with toileting needs. All allegations were determined to be unsubstantiated or unfounded.

The complaint involved allegations that staff did not respond to residents' call buttons in a timely manner, did not ensure adequate nighttime supervision, and did not meet residents' toileting needs. After investigation including interviews and record reviews, all allegations were found to be unsubstantiated or unfounded.

The inspection was an unannounced complaint investigation visit triggered by allegations received on 2023-09-22 regarding medication record maintenance, timely treatment, care plan adherence, overcharging, and communication with residents' responsible parties.

The investigation found all allegations to be either unsubstantiated or unfounded. Medication records were properly maintained, treatment was timely, care plans were followed, no overcharging occurred, and effective communication with residents' responsible parties was ensured.

The complaint investigation was unsubstantiated for the allegation that staff did not properly maintain medication records. Other allegations including failure to seek timely treatment, failure to follow care plans, overcharging, and ineffective communication were found to be unfounded.

An unannounced complaint investigation was conducted in response to multiple allegations regarding staff not dispensing medication as prescribed and various care deficiencies.

The investigation found insufficient evidence to substantiate the medication allegation, and all other allegations related to diet, care plans, supervision, call systems, hygiene, dental care, bathroom cleanliness, toileting, and laundering were determined to be unfounded based on interviews, observations, and documentation review.

The complaint involved multiple allegations including failure to dispense medication as prescribed, failure to follow diabetic diet and care plans, inadequate supervision, lack of call assistance, and unmet hygiene, dental, bathroom, toileting, and laundering needs. The medication allegation was unsubstantiated, and all other allegations were unfounded.

An unannounced complaint investigation was conducted in response to an allegation that staff gave a resident another resident's medication.

The investigation found that the medication was incorrectly labeled by the pharmacy and administered to the wrong resident for four days. The facility ceased administration upon discovery, notified the physician, and the resident experienced no side effects. The allegation was determined to be unfounded.

The complaint alleged that staff gave a resident another resident's medication. The investigation concluded the allegation was unfounded due to pharmacy labeling error and no harm to the resident.

The inspection was an unannounced complaint investigation visit conducted in response to allegations received on 2023-07-10 regarding resident care issues including soiled diapers, lack of showers, and delayed response to call bells.

The investigation included interviews with staff and residents, record reviews, and facility observations. All allegations were found to be unfounded, meaning the complaints were false or without reasonable basis.

The complaint included three allegations: residents left in soiled diapers for extended periods, staff not providing showers, and staff not responding to call bells timely. After investigation, all allegations were determined to be unfounded.

The inspection was conducted as the required annual unannounced inspection to evaluate compliance with regulatory standards.

The facility was found to be clean, well organized, and compliant with health and safety regulations. All resident and staff files contained the required paperwork, staff had current first aid and CPR training, and no health or safety violations were observed during the tour.

Unannounced complaint investigation visit conducted due to a complaint received on 10/12/2022 regarding the facility not reimbursing or replacing stolen or lost resident property at its current value.

The investigation substantiated the allegation that the facility had not reimbursed or replaced stolen or lost resident property at its current value. However, the facility provided a refund in the form of one-month free rent valued at $8,793.00 as of 11/10/2022, resolving the issue without citation.

The complaint was substantiated based on the preponderance of evidence standard. The facility resolved the issue by providing a refund in the form of one-month free rent at $8,793.00. No citation was issued.

The visit was an unannounced complaint investigation triggered by allegations that staff were not adhering to the resident's care plan and not assisting residents with activities of daily living (ADLs).

The investigation substantiated that the facility did not meet resident R1's needs from August 2021 through March 2022 due to an incorrect assessment at admission. The facility conducted a reassessment in March 2022 and is currently meeting R1's needs.

The complaint was substantiated based on evidence that the facility failed to meet resident R1's needs between August 2021 and March 2022 due to an incorrect needs assessment at admission. The facility has since reassessed and corrected the service plan.

The visit was an unannounced required 1 year Annual Inspection conducted by the Licensing Program Analyst.

No deficiencies were observed or cited during the visit. The facility was found to be in compliance with California Code of Regulations, Title 22, and the fire extinguisher and fire code inspection were up to date and compliant.

An unannounced complaint investigation visit was conducted in response to allegations including medication administration errors and failure to release medical records upon request.

The complaint regarding medication administration errors was substantiated based on record review showing one medication administered at incorrect times and misclassification of medication orders. The facility conducted an internal audit and is currently administering medications as prescribed.

The complaint was substantiated based on evidence that facility staff made medication administration errors with resident R1's medications. The preponderance of evidence standard was met.

The inspection was an unannounced complaint investigation visit triggered by an allegation that facility staff were not allowing family member visitation.

The investigation found the allegation to be unfounded. The facility was following the strictest guidelines set by local public health authorities regarding visitation restrictions due to a COVID-19 outbreak.

The complaint alleged that facility staff were not allowing family member visitation. The allegation was found to be unfounded after interviews and record reviews, confirming the facility was complying with local public health directives to restrict visitation in portions of the facility during a COVID-19 outbreak.

An unannounced complaint investigation was conducted in response to an allegation that facility staff did not keep a resident's medical condition confidential.

The investigation found that a resident overheard staff discussing her medical condition outside her apartment door, but there was no evidence that unauthorized persons overheard the conversation. The allegation was determined to be unsubstantiated due to lack of preponderance of evidence.

The complaint was unsubstantiated. Although the allegation may have happened or is valid, there was not enough evidence to prove the violation occurred.

An unannounced complaint investigation visit was conducted in response to an allegation that facility staff did not follow doctor's orders.

The facility admitted to failing to follow medical doctor orders, resulting in a treatment delay of approximately two weeks for a resident. The allegation was substantiated based on witness statements and evidence.

The complaint was substantiated. Facility staff did not follow doctor's orders, causing a treatment delay of approximately two weeks for a resident's medical condition.

An unannounced complaint investigation visit was conducted in response to allegations received on 2021-12-01 regarding staff mismanaging and inappropriately logging resident medication.

The investigation found no conclusive evidence to support the allegations. The facility's medication administration records were reviewed and appeared to be in order, resulting in the allegations being unsubstantiated.

The complaint was unsubstantiated based on investigation, documentation, and witness statements. Although the allegations may have happened or be valid, there was not a preponderance of evidence to prove the alleged violation occurred.

An unannounced complaint investigation visit was conducted in response to allegations received on 2020-12-09 regarding staff not responding to resident call lights timely, residents not fed timely, poor food quality, and unmet hygiene needs.

The investigation found no witnesses or evidence to substantiate the allegations. The complaint was determined to be unsubstantiated, meaning there was insufficient evidence to prove the alleged violations occurred.

The complaint was unsubstantiated due to lack of witnesses and evidence to confirm or deny the allegations related to staff response times, feeding, food quality, and hygiene.

Case management visit to review documents from a previous complaint, including admission agreement documents, unusual incident reports, and LIC 9060s.

The licensing program analyst received, reviewed, and retained copies of the requested documents related to a prior complaint.

An unannounced complaint investigation visit was conducted due to allegations that the facility was not safeguarding residents' personal property, following multiple reported thefts.

The allegation that the facility failed to safeguard residents' personal property was substantiated based on numerous documented thefts from resident rooms over the past four months, including a police report for theft/burglary. The licensee did not take necessary steps to prevent continued thefts, posing a potential health and safety risk.

The complaint was substantiated. The allegation was that the facility was not safeguarding resident's personal property, supported by multiple theft reports and a police report. The preponderance of evidence standard was met.

Plan of correction visit to clear the deficiency from the 10/11/21 complaint visit. The plan of correction was due on 10/18/21 but had not been submitted as of 10/19/21.

The plan of correction had not been submitted for review and clearance by the due date. A civil penalty of $100 was issued and will accrue at $100 per day until the deficiency is corrected.

This visit was a follow-up to a complaint visit dated 10/11/21. The deficiency from that complaint was not corrected as the plan of correction was not submitted by the due date.

Unannounced complaint investigation visit conducted due to allegations that facility staff did not safeguard a resident's property and did not clean/sanitize a resident's room.

The investigation substantiated the allegations that facility staff failed to safeguard a resident's wheelchair, which was missing, and did not properly clean/sanitize the resident's room, as evidenced by photographic documentation.

The complaint was substantiated based on evidence including a missing wheelchair and photographic evidence of unsanitary conditions in a resident's room.

Unannounced complaint investigation visit conducted due to an allegation that a resident was not receiving the proper care needed.

The allegation was substantiated based on photographic evidence, medical documentation, and witness testimony showing uncut toenails and unbrushed teeth on a resident, indicating lack of routine hygienic care.

The complaint was substantiated based on evidence including photographic and medical documentation and witness testimony. The allegation that the resident was not receiving proper care was found valid.

Unannounced annual visit utilizing the infection control domain was performed to evaluate compliance and staff background clearances.

No deficiencies were found during the inspection; however, 2 technical violations were issued.

Unannounced complaint investigation visit conducted due to complaints received on 12/14/2020 regarding resident dehydration and visitation restrictions.

The investigation substantiated that the resident was severely dehydrated while in care and that the facility restricted visitation improperly. Other allegations including failure to follow care plan for feeding and hydration, retaining resident beyond level of care, falsifying resident's name, chemical restraint, and failure to follow mandated reporter requirements were found unsubstantiated.

Complaint was substantiated for allegations of severe dehydration and visitation restrictions. Other allegations including failure to follow care plan, retaining resident beyond level of care, falsifying resident's name, chemical restraint, and failure to follow mandated reporter requirements were unsubstantiated.

The inspection was an unannounced complaint investigation visit triggered by multiple allegations including inadequate medication management, resident neglect resulting in a pressure injury, and residents not getting their needs met.

The investigation substantiated the allegation of inadequate medication management due to staff failing to provide medications timely, resulting in termination of the responsible staff. The allegation of resident neglect causing a pressure injury was unsubstantiated, and the allegation that residents were not getting their needs met was found to be unfounded.

The complaint investigation was substantiated for medication management inadequacies, unsubstantiated for neglect resulting in pressure injury, and unfounded for residents not getting their needs met.

Case management visit regarding the review of the facility Disaster Plan - LIC 610E and the facility Disaster and Emergency Manual.

The facility is in compliance with Title 22, Section 87212 Emergency Disaster Plan. However, a staff member was observed wearing a mask improperly, constituting a technical violation.