Inspection Reports for
Oakmont of Fair Oaks

The visit was related to substantiated complaint allegations totaling 23 since licensing; the follow-up meeting addressed compliance after these complaints.

The facility is maintaining ongoing compliance with open communication with the Department and receiving assistance from the Technical Support Program. Increased monitoring will continue as deemed necessary to ensure ongoing compliance.

The complaint investigation was substantiated for medication mismanagement, unsubstantiated for failure to provide assistance with ADLs, and unfounded for retaining residents beyond the level of care. The medication mismanagement involved discrepancies in medication counts and documentation for residents R1, R2, R3, and R4.

The investigation substantiated the allegation that facility staff mismanaged residents' medications, citing deficiencies related to medication administration. The allegation that staff were not providing assistance with ADLs was unsubstantiated. The allegation that the facility was retaining residents beyond a level of care they can provide was found to be unfounded.

The complaint investigation was substantiated for medication mismanagement, unsubstantiated for failure to provide assistance with ADLs, and unfounded for retaining residents beyond a level of care the facility can provide.

The investigation substantiated the allegation that facility staff mismanaged residents' medications, citing deficiencies related to medication counts and records. The allegation that staff were not providing assistance with ADLs was unsubstantiated based on interviews and observations. The allegation that the facility was retaining residents beyond a level of care they can provide was found to be unfounded after review of records and interviews.

The complaint investigation was substantiated regarding the allegation that the facility is not addressing resident sustaining falls. Other allegations including uncleanliness, inadequate catheter assistance, inadequate food services, and improper hygiene assistance were unsubstantiated.

The investigation substantiated that the facility failed to immediately contact 9-1-1 after a resident sustained falls with potential head injuries on two occasions, posing an immediate health and safety risk. Other allegations regarding cleanliness, catheter assistance, food services, and hygiene assistance were found to be unsubstantiated based on interviews, observations, and record reviews.

The complaint investigation was substantiated regarding the facility's failure to address resident falls properly, specifically not calling 9-1-1 after falls with potential head injuries. Other allegations about cleanliness, catheter care, food services, and hygiene assistance were unsubstantiated.

The investigation substantiated that the facility failed to immediately call 9-1-1 after a resident sustained falls with potential head injuries on two occasions, posing an immediate health and safety risk. Other allegations regarding cleanliness, catheter assistance, food services, and hygiene assistance were found to be unsubstantiated based on interviews, observations, and record reviews.

The facility had repeat violations related to medication errors and medication management. The facility committed to enforcing quality assurance systems for medication management and ensuring staff competency through required training.

23 substantiated complaint allegations since licensing on July 27, 2021.

The facility had repeat violations related to medication errors and medication management. The facility committed to enforcing quality assurance systems for medication management and ensuring staff competency through required training.

The complaint was substantiated. The allegation was that staff were not adequately trained on emergency evacuation protocols following a fire on February 1, 2025. Interviews and documentation review confirmed inadequate training and incomplete evacuation during the fire.

The investigation substantiated the allegation that staff were not properly trained on emergency evacuation protocols. Interviews with staff revealed inadequate training and participation in drills. The fire was contained to the laundry room with no injuries, but some residents were not evacuated properly. The facility's Plan of Operation lacked specific training objectives and documentation did not comply with Title 22 regulations.

The complaint was substantiated. The allegation was that staff were not adequately trained on emergency evacuation protocols during a fire on February 1, 2025. The investigation included interviews with staff and review of training documentation, confirming inadequate training and incomplete evacuation during the fire.

The investigation substantiated the allegation that staff were not adequately trained on emergency evacuation protocols. Interviews and documentation review revealed deficiencies in staff training and emergency preparedness, including incomplete evacuation during the fire and inadequate training records in accordance with the facility's Plan of Operation.

The facility was found to have an administrator without an active Administrator certificate, which poses potential health, safety, and personal rights risks to residents. A deficiency was cited and a plan of correction was required.

The facility was found to have an administrator without an active Administrator certificate, which poses a potential health, safety, and personal rights risk to residents in care.

The complaint investigation was substantiated for the allegation that staff were not meeting a resident's oxygen needs while in care. Other allegations about a defective call button, inadequate care and supervision, and lack of planned activities were unsubstantiated.

The investigation substantiated the allegation that staff did not ensure a resident's oxygen needs were met according to physician's orders, posing an immediate health and safety risk. Other allegations regarding the defective call button, inadequate care and supervision, and lack of planned activities were found to be unsubstantiated based on interviews, observations, and record reviews.

The complaint investigation was substantiated for the allegation that staff were not meeting a resident's oxygen needs while in care. The other allegations regarding a defective call button, inadequate care and supervision, and lack of planned activities were unsubstantiated.

The investigation substantiated that staff failed to ensure a resident used oxygen as ordered, posing an immediate health and safety risk. Other allegations regarding a defective call button, inadequate care and supervision, and lack of planned activities were found to be unsubstantiated based on interviews, observations, and documentation.

The complaint was substantiated based on interviews, medication count, observation, and records review. The allegations involved medication administration errors and inadequate PPE provision to staff. Two civil penalties were assessed for repeat violations within 12 months.

The investigation substantiated that the facility failed to ensure resident R1 received medications as prescribed and that staff did not consistently wear full PPE when caring for residents in isolation due to COVID-19. Two civil penalties of $250 each were assessed for repeated violations.

The complaint was substantiated based on interviews, medication counts, observations, and record reviews. The allegations involved medication administration errors and inadequate PPE use by staff. Two civil penalties were assessed for repeated violations within 12 months.

The investigation substantiated the allegations that resident R1 did not receive medications as prescribed, posing an immediate health and safety risk, and that staff were not wearing full PPE when caring for residents in isolation for COVID-19, posing a potential health and safety risk. Two civil penalties of $250 each were assessed for repeated violations.

The complaint was substantiated based on interviews, medication counts, and record reviews. The allegation involved staff mismanagement of resident R1's medication, including delayed delivery and inaccurate medication documentation.

The investigation found that resident R1 was discharged with new medication orders that were delayed in delivery to the facility. Medication counts revealed discrepancies with two medications being under the documented amount, confirming the allegation of medication mismanagement. A deficiency was cited and a civil penalty assessed.

The complaint was substantiated. The investigation included interviews, medication counts, and record reviews. A civil penalty of $250 was assessed for a repeat violation within 12 months.

The investigation found that resident R1 did not receive new medications as prescribed after hospital discharge, with medication delivery delays and discrepancies in medication counts. The allegation was substantiated, and a deficiency was cited for failure to assist residents with self-administered medications.

The complaint investigation was substantiated for allegations related to resident sustaining pressure injuries, failure to seek timely medical care, lack of assistance with incontinence care, and medication mismanagement. Other allegations such as lack of supervision causing falls, safeguarding personal property, feeding assistance, and cleanliness were unsubstantiated.

The investigation substantiated allegations that the facility failed to provide proper care for a resident's pressure injuries and timely medical attention, and medication mismanagement was identified. The facility also failed to provide assistance with incontinence care for a resident. Other allegations including lack of supervision resulting in falls, safeguarding of personal property, feeding assistance, and cleanliness were found unsubstantiated.

The complaint investigation was substantiated. Allegations included resident sustaining pressure injuries without timely medical care, lack of assistance with incontinence care and medications, and medication mismanagement. The investigation found that resident R1 had unstageable pressure wounds that were not properly treated, and medication errors occurred. An immediate civil penalty of $500 was assessed due to serious bodily injury. Other allegations such as lack of supervision causing falls, failure to safeguard personal property, lack of feeding assistance, and unclean conditions were unsubstantiated.

The investigation substantiated that the facility failed to provide proper care and medical attention for pressure injuries, resulting in serious bodily injury and a $500 civil penalty. Medication mismanagement and inadequate incontinence care were also substantiated. Other allegations including lack of supervision causing falls, failure to safeguard personal property, lack of feeding assistance, and unclean conditions were found unsubstantiated based on interviews, observations, and record reviews.

The complaint investigation was substantiated. Allegations included residents not receiving showers and staff not dispensing medications. Evidence included interviews, medication audits, medication counts, and review of resident assessments and facility documentation.

The investigation substantiated the allegations that facility staff failed to assist residents with bathing, with one resident going 5 to 6 weeks without a shower despite requiring hands-on assistance. Medication mismanagement was also found, including discrepancies in medication counts and improper documentation of medication administration.

The complaint investigation was substantiated. Allegations included staff mismanaging medications, not assisting residents with incontinence care, and not assisting residents with bathing. Evidence included medication audits, interviews with residents and staff, and review of resident assessments and facility documentation.

The investigation substantiated the allegations that facility staff mismanaged medications and failed to provide timely assistance with incontinence care and bathing to resident R1. Documentation and interviews revealed inconsistent care and delays in providing necessary equipment such as a shower chair, posing potential health, safety, and personal rights risks to residents.

The complaint investigation was substantiated. Allegations included failure to meet residents' care needs, insufficient staffing, lack of oxygen signage, medication mismanagement, and inadequate staff training. Some allegations about food quality, visitation, and cleanliness were unsubstantiated.

The investigation substantiated several allegations including failure to provide adequate incontinence care and bathing assistance, insufficient staffing leading to delayed response times, lack of proper oxygen signage, medication mismanagement including inaccurate medication counts and improper approvals, and inadequate staff training hours. Some allegations regarding food quality, visitation, and facility cleanliness were found unsubstantiated.

The complaint was substantiated. The allegation was that the facility did not have adequate staffing to meet residents' needs, supported by interviews and call button response time records.

The investigation found the allegation substantiated based on staff interviews and review of call button response time records, which showed response times exceeding 15 minutes and up to 42 minutes, posing a potential health and safety risk to residents.

The complaint alleged inadequate staffing to meet residents' needs. The allegation was substantiated based on interviews with staff and residents, and review of call button response time records showing delays up to 42 minutes.

The investigation found substantiated evidence that the facility did not ensure timely response to residents' call buttons, with response times reaching as long as 42 minutes, posing potential health, safety, and personal rights risks to residents.

The Licensing Program Analyst observed that residents' care needs were being met, PPE supplies and staffing were sufficient, and infection prevention measures were generally adequate. However, a deficiency was cited for failure to report COVID-19 cases to the licensing agency within the required timeframe.

The Licensing Program Analyst observed that residents' care needs were being met, PPE supplies and staffing were sufficient, and infection prevention measures were generally adequate. However, a deficiency was cited for failure to report COVID-19 positive cases to the licensing agency within 24 hours as required by regulations.

Complaint investigation was substantiated for allegations that staff failed to respond to resident's call button and left resident unattended for extended periods. The allegation of untrained staff was also substantiated. The allegation that the resident sustained a fall due to neglect was unfounded.

The investigation substantiated that staff did not respond timely to the resident's calls for assistance on multiple occasions, leaving the resident unattended for hours, and that three of five staff lacked required initial or annual training. One allegation regarding a resident fall was found to be unfounded.

The complaint was substantiated. Allegations included staff failing to respond to resident's call button, leaving resident unattended for hours after a fall, and untrained staff. The investigation found evidence supporting these allegations based on interviews, documentation review, and pendant response records. One allegation about a resident fall was unfounded.

The investigation substantiated allegations that staff failed to respond timely to a resident's call pendant on multiple occasions, leaving the resident unattended for extended periods, and that some staff lacked required initial or annual training. One allegation regarding a resident fall was found to be unfounded.