Inspection Reports for Sierra Oaks Assisted Living & Memory Care

An unannounced complaint investigation was conducted in response to an allegation that the facility was understaffed, resulting in residents waiting for assistance.

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

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

The visit was an unannounced case management inspection conducted to follow up on an incident report regarding a resident who sustained a fractured right femur.

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

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

The inspection was an unannounced Required-1 Year annual inspection to ensure the health and safety of residents in care.

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

The inspection was conducted as a Case Management-Incident visit to review an incident report dated December 16, 2024, and to assess the facility's compliance with incident reporting regulations.

No deficiencies were cited during the Case Management-Incident inspection. The Licensing Program Analyst educated the Administrator on proper incident reporting as outlined in Title 22 regulations.

The visit was complaint-related, reviewing an incident report. The facility was not late in reporting but made a reporting error. No deficiencies were cited.

The inspection was conducted as a Case Management-Incident Inspection following a reported medication error incident at the facility.

The inspection found that a caregiver gave the wrong medication to a resident, but no adverse reactions occurred. The caregiver is no longer passing medication and is in training. No deficiencies were cited during the inspection.

The visit was complaint-related due to a medication error incident reported on September 16, 2024. The incident was substantiated with no adverse reactions reported. Responsible parties and the physician were notified.

The inspection was an unannounced complaint investigation visit conducted in response to a complaint received on 2024-04-03 regarding staff not mitigating the spread of scabies in the facility.

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

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

The visit was an unannounced 1-Year Required Annual Inspection conducted to ensure the health and safety of residents in care at the facility.

The facility was generally clean, odor-free, and well-maintained with proper safety equipment and documentation. However, two of eleven bathrooms had damage posing an immediate health, safety, or personal rights risk to residents, resulting in cited deficiencies.

The inspection was an unannounced complaint investigation visit conducted in response to a complaint received on 2023-11-16 regarding a resident sustaining an injury from another resident while in care.

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

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

The inspection was an unannounced complaint investigation visit triggered by a complaint received on 2023-04-17 regarding multiple allegations including failure to report incidents to responsible parties, staff negligence, and failure to meet resident care and dietary needs.

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

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

An unannounced annual inspection was conducted to evaluate the facility's compliance with licensing requirements and assess the condition of the premises and care provided.

No deficiencies were cited during the inspection. Some issues were noted such as flooring lifting in building three and missing ends on handrails in building one, but these were not cited as they did not pose immediate hazards. The facility was advised to submit a waiver request for the locked perimeter gates.

The inspection was an unannounced complaint investigation visit triggered by a complaint received on 2022-09-28 alleging that facility staff were not properly trained and that the facility kitchen refrigerator door was in disrepair.

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

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

An unannounced complaint investigation was conducted following a complaint received on 07/29/2022 alleging financial abuse related to failure to issue a refund upon the death of a resident and removal of the resident's personal property.

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

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

The visit was an announced health and safety case management check conducted by Licensing Program Analysts to ensure compliance with health protocols and assess the facility's handling of relocated residents due to a nearby wildfire evacuation.

No deficiencies were cited during the visit. The facility was found to be adequately staffed, with sufficient food supply and accommodations for the additional residents relocated due to the McKinney Fire. Residents reported satisfaction with care and food.

The visit was conducted as a Post-Licensing visit to evaluate the facility following licensing.

The facility was toured and inspected, including client rooms, bathrooms, and common areas. All safety equipment was operational, and no deficiencies were found during the visit.

The visit was conducted as a pre-licensing inspection and Comp III Orientation to evaluate the facility's readiness for licensing and to confirm compliance with applicable regulations.

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