OAKMONT OF BROOKSIDE

Official classification

Type B

Official code

87468.1(a)(1)

Regulation authority

CCR

What the official deficiency says

(a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (1) To be accorded dignity in their personal relationships with staff, residents, and other persons. This requirement is not met as evidenced by R1 not granted permission for staff to open pharmacy deliveries on his behalf. This is a personal right violation.

Official plan of correction

The facility shall submit a plan on how this will not occur in the future along with a current in- service training on 87468.1 personal rights by POC due date. Please provided documentation to CCL by POC

Deadline recorded: Apr 10, 2026. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87465(d)(1)

Regulation authority

CCR

What the official deficiency says

87465 Incidental Medical and Dental Care (d) If the resident is unable to determine his/her own need for a prescription or nonprescription PRN medication, and is unable to communicate his/her symptoms clearly, facility staff designated by the licensee, shall be permitted to assist the resident with self-administration provided all of the following requirements are met:(1)Facility staff shall contact the resident's physician prior to each dose, describe the resident's symptoms, and receive direction to assist the resident in self-administration of that dose of medication. This requirement was not met as evidenced by records reviewed and interviews with staff. The facility is not following the Doctor's orders as requested in the current and outdated PRN letters for R1 through R7

Official plan of correction

Facility Administrator will review the section, 87465(d)(1). A statement of correction, along with proof of staff training for no less than (1) hour in duration, for the cited section will be completed and submitted to the LPA’s email by the due date of 8/21/2025 COB at 5:00pm. Information submitted must include. Attendees, trainers, and information discussed.

Deadline recorded: Aug 21, 2025. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87303(a)

Regulation authority

CCR

What the official deficiency says

87303 Maintenance and Operation (a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. This requirement was not met as evidenced by records reviewed The alarm system was triggering more frequently than usual from 9/24/2024 through 10/232024. The facility did not have a Maintenance Director at the time of the incidents and the staff or Administrator would have to call Phillips lifeline systems to have the system reset after putting a code in to stop the alarm.

Official plan of correction

The facility repaired the system of 10/23/2024. The facility provided an invoice #1307 dated 1/30/2025 and currently uses a remote to stop the alarm when triggered. The facility submitted a letter to the Division of Occupational Safety and Health dated 3/26/2025 regarding complaint # 2274922 with inaccurate information about the Department's findings and will need to report the current findings to Mr. Valadez of the Dept. of Industrial Relations(DIR)/ Division of Occupational Safety and Health by 4/21/2025. The Department will also cross report the current and accurate findings to DIR.

Deadline recorded: Apr 25, 2025. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87468.1(a)(2)

Regulation authority

CCR

What the official deficiency says

87468.1 Personal Rights of Residents in All Facilities (a) Residents in all residential care facilities for the elderly shall have all of the following personal rights:(2) To be accorded safe, healthful and comfortable accommodations, furnishings and equipment. This requirement was not met as evidenced by based on the repair and auditory frequency of the alarm going off the residents in care with or without hearing impairments were subjected to the loud noise and as a result were exposed to a uncomfortable environment.

Official plan of correction

The facility repaired the system of 10/23/2024. The facility provided an invoice #1307 dated 1/30/2025 and currently uses a remote to stop the alarm when triggered.

Deadline recorded: Apr 25, 2025. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87203

Regulation authority

CCR

What the official deficiency says

87203 Fire Safety This requirement is not met as evidenced by: Deficient Practice Statement Based on observation; the facility did not comply with the regulations adopted by the State Fire Marshal. The " Fixed System " or " Ansul System " in the kitchen is scheduled for a semi-annual maintenance and was last serviced on 9/27/2023. This poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 08/20/2024 Plan of Correction Licensee/Administrator will ensure that the fire equipment listed is inspected or a plan is made and sent to CCL by the POC date indicated. Licensee/Administrator shall send picture of the new tags. As proof and submit Statement of Compliance by POC date.

Official classification

Type A

Official code

87464(f)(1)

Regulation authority

CCR

What the official deficiency says

87464 (f)(1) Basic services care and supervision as defined in Section 87101(c)(3) and Health and Safety Code section 1569.2(c). This requirement is not met as evidence by: Based on the department's findings, the facility did not provide adequate care and supervision including a two person assist which resulted in R1 sustaining a fracture from a fall while transferring. This posed an immediate health and safety risk to R1.

Official plan of correction

Licensee agrees to submit a plan of correction to LPA by 5/15/2024 on how the facility will be in compliance with regulation 87464(f)(1) at all times. Civil penalty assessed

Deadline recorded: May 15, 2024. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87705(c)(5)

Regulation authority

CCR

What the official deficiency says

87705(c)(5)Care of Persons with Dementia Licensees who accept and retain residents with dementia shall ensure that each resident with dementia has an annual medical assessment and a reappraisal done at least annually This requirement was not met based on records reviewed, The department observed R3 with an outdated LIC 602/ Physician report expired. This poses a potential health and safety risk to residents in care.

Official plan of correction

All residents diagnosed with dementia will be scheduled with their responsible physician and be assessed for any changes to their needs with an updated LIC 602. Statement of correction, with copy of updated LIC 602, to be completed and submitted into CCL by the due date

Deadline recorded: May 17, 2024. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87464(f)(6)

Regulation authority

CCR

What the official deficiency says

87464 Basic Services (f) Basic services shall at a minimum include: (6) Arrangements to meet health needs, including arranging transportation, as specified in Section 87465, Incidental Medical and Dental Care Services. This requirement was not met as evidenced by The facility not following the doctors orders and not taking R1 to be checked after the fall on 12/3/23 at the request of the PCP. R1 had another fall at approximately 3 pm and was told by POA not to transport R1 via ambulance. Later in the evening R1 requested to go to the ER and was diagnosed with fractured ribs.

Official plan of correction

Licensee to ensure all staff are up to date and are knowledgeable of the latest PINs and regulations. LPA to receive confirmation of review of the last PIN with staff by POC due date.

Deadline recorded: Mar 22, 2024. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87465(a)(1)

Regulation authority

CCR

What the official deficiency says

Incidental Medical and Dental Care. (a) plan for incidental medical and dental care shall be developed by each facility (1)The licensee shall arrange, or assist in arranging, for medical and dental care appropriate to the conditions and needs of residents. This requirement is not met as evidenced by: Based on record reviews and interviews, licensee did not ensure physician was efficiently notified for medication order clarification for R1. This poses an immediate health and safety risk to residents in care.

Official plan of correction

Licensee will submit a plan which ensures physician’s are efficiently and effectively notified for any resident care needs. Plan to be submitted to LPA by POC due date.

Deadline recorded: Mar 22, 2024. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87411(a)

Regulation authority

CCR

What the official deficiency says

(a) Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs. In facilities licensed for sixteen or more, sufficient support staff shall be employed to ensure provision of personal assistance and care as required in Section 87608, Postural Supports. Additional staff shall be employed as necessary to perform office work, cooking This requirement was not met as evidenced by R1 being without medication for seven days. This is a potential health and safety risk to resident in care

Official plan of correction

The facility shall conduct a staff in-service training with all staff who distribute medication on proper medication storing and ordering, distribution, training shall include but is not limited to applicable laws in regards to medications. Proof of training shall be sent to Licensing by 03/22/2024

Deadline recorded: Mar 22, 2024. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87405(a-d)

Regulation authority

CCR

What the official deficiency says

87405(a-d) All Facilities shall have a qualified and currently certified administrator.... This requirement was not met as evidenced by records reviewed and interviews with staff. This is an immediate risk to operations and care of residents.

Official plan of correction

Licensee will submit to LPA an updated LIC500, LIC200 and other documents required with an employee who has a current administrator certificate and who will act in the administrator capacity until Licensee finds and updates the Administrator positions. Licensee will send to LPA by end of day on 1/17/2024

Deadline recorded: Jan 17, 2024. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87355(e)(2)

Regulation authority

CCR

What the official deficiency says

(e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility: (2) Request a transfer of a criminal record clearance as specified in Section 87355(c) or... Based on observation, the Licensee did not ensure all staff were associated to the facility. The LPA observed that S1 was not associated to the facility. This poses an immediate health and safety risk to residents in care.

Official plan of correction

The Licensee will request a criminal record transfer for S1. The Licensee will review the staff roster and ensure all working staff are associated to the facility. Proof of S1 being associated to the facility due by the POC due date of 1/17/2024.

Deadline recorded: Jan 17, 2024. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87465(c)(2)

Regulation authority

CCR

What the official deficiency says

87465(c)(2) Incidental Medical and Dental Care. Once ordered by the physician the medication is given according to the physician's directions. This requirement is not met as evidenced by: Based on observation and records review, the Licensee did not ensure medications ordered for residents are given as prescribed which poses an immediate health and safety risk to residents in care.

Official plan of correction

The Administrator will developed a plan on how the facility will follow the Physician's orders and document correctly when medications are missed. Please send the agenda along with the sign-in sheet for the in-service, by POC date or give a time when the training will take place and send that information to the department The facility will also report all incidents of medication errors, missed medication Etc.. to the resident's Primary Care Physician and to the department.

Deadline recorded: Aug 29, 2023. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87555(b)(9)

Regulation authority

CCR

What the official deficiency says

(b) The following food service requirements shall apply:..... (9) Procedures which protect the safety, acceptability and nutritive values of food shall be observed in food storage, preparation and service. This requirement was not met as evidenced by: LPA, Administrator and kitchen staff observed expired food in the main kitchen area, uncovered food, missing temperature checks for foods served, and no labels on prepared food

Official plan of correction

Facility agrees to a deep cleaning of kitchen and food storage area. The facility manager indicated that a kitchen staff membesr recently ended their employment and new kitchen staff are on board. Facility agrees that kitchen staff will be trained and monitored on proper sanitation practices as well as food storage and service. The facility will provide the department with an in- service agenda with those that attend by the POC date of 7/24/2023

Deadline recorded: Jul 24, 2023. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87464(f)(1)(c)

Regulation authority

CCR

What the official deficiency says

Basic Services (c) " Care and supervision " means the facility assumes responsibility for, or provides... assistance with activities of daily living without which the resident’s physical health, mental health, safety, or welfare would be endangered. Assistance includes ...personal care and supervision. This requirement was not met as evidenced by R1's Companion was not around or failed to report that they were leaving the facility. As a result, R1 was unaccounted for and was in the community without supervision. This poses an immediate health and safety risk and hazard.

Official plan of correction

Licensee will provide a schedule to ensure staffing for residents in care, have all paid assistants finger print cleared and associated to the facility. Facility Administrator will ensure ongoing compliance by increased observations for R1 and if needed staffing to meet R1's needs. Written plan due to CCL by 6/1/22.

Deadline recorded: Jun 1, 2022. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87470(b)

Regulation authority

CCR

What the official deficiency says

(b) In addition to subsection (a), when one or more residents in the facility are diagnosed with a communicable disease, the following shall apply: (1) In addition to the requirements of subsection (a)(2), assigned staff and volunteers, regardless of having direct contact with clients, shall be required to perform enhanced environmental cleaning and disinfection to maintain a safe and sanitary environment and to prevent, contain, and mitigate the transmission of the communicable disease. Enhanced environmental cleaning and disinfection shall be of: (A) all frequently touched surfaces such as doorknobs, handles, and shared items, as well as, (B) when one or more client(s) has a communicable disease, in any impacted areas, and immediately after contact with a client who has a communicable disease. (2) All staff and volunteers providing direct care to a resident who has a communicable disease shall wear appropriate Personal Protective Equipment (PPE) to prevent exposure to infectious agents or chemicals through the respiratory system, skin, or mucous membranes of the eyes, nose, or mouth. PPE may include gloves, gowns, masks, respirators, shoe coverings and eye protection. .... This requirement was not met as evidenced by records reviewed and interviews conducted. The facility failed to address the infection response protocols. This is an immediate health and safety risk to residents in care.

Official plan of correction

The licensee will develop a plan for notifiying and addressing outbreaks at the facility. The plan will be submitted to the department by POC date.

Deadline recorded: Apr 30, 2022. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87458(b)(1)

Regulation authority

CCR

What the official deficiency says

87458(b)(1) Medical Assessment. The medical assessment, at a minimum, shall include: A physical exam of the resident containing a primary and secondary diagnosis, if any, results of a test for tuberculosis and any medical conditions which would preclude care of the person in an RCFE. R1 does not have a current TB test. This poses a potential health and safety risk to residents in care.

Official plan of correction

Administrator shall obtain a TB clearance for R1 and send proof to Licensing prior to R1 returning to the facility.

Deadline recorded: Dec 16, 2021. A deadline is not proof that correction was completed.