OAKMONT OF RIVERPARK

Official classification

Type B

Official code

1569.652(c)

Regulation authority

HSC

What the official deficiency says

§1569.652 Termination of admission agreement upon death of resident... and refunds (c) A refund of any fees paid in advance...shall be issued...to the resident’s estate, within 15 days after the personal property is removed.This requirement is not met as evidenced by Based on interviews and record review, the facility did not comply with the above cited section, as R1 passed away on 10/07/25, belongings were removed on 10/17/25 and check was received on 12/27/25, which poses a potential personal rights risk to persons in care.

Official plan of correction

On 1/20/26, AR of R1 confirmed they had received the refund from the facility and the ED also agreed to review section cited and submit a statement of understanding and plan to ensure future compliance and send to LPA by 01/30/2026. Additionally, the ED stated they have informed their legal department to ensure future compliance.

Deadline recorded: Jan 30, 2026. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87468.2(a)(4)

Regulation authority

CCR

What the official deficiency says

87468.2(a)(4)residents…shall have all of the following personal rights: To care, supervision, and services that meet their individual needs and are delivered by staff that are sufficient in numbers, qualifications, and competency to meet their needs.This requirement is not met as evidence by: Based on records review, the licensee did not comply with the section cited above as Staff did not respond to R1’s call for assistance in a timely manner, which posed a potential health and safety risk to residents in care.

Official plan of correction

ED agreed to have an in service with all staff regarding how to respond resident calls in a timely manner and charting if resident refuses staff to clear the call. Will submit proof of inservice to CCL by 08/29/25

Deadline recorded: Aug 29, 2025. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87506(a)

Regulation authority

CCR

What the official deficiency says

87506 Resident Records (a) The licensee shall ensure that a separate, complete, and current record is maintained for each resident in the facility or in a central administrative location readily available ...This requirement is not met as evidenced by: Based on interviews and file review the licensee did not comply with the section cited above as R1's emergency packet was not updated with the resident correct POA information which posed a potential health and safety or personal risk to persons in care.

Official plan of correction

Information has been updated. Licensee agrees to submit a letter of understanding of regulation 87506 in its entirety by 08/21/25.

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

Official classification

Type B

Official code

87303(a)(1)

Regulation authority

CCR

What the official deficiency says

87303(a)(1) 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. (1) Floor surfaces in bath, laundry and kitchen areas shall be maintained in a clean, sanitary, and odorless condition. This requirement is not met as evidenced by:Based on observations and interview, the licensee did not comply with the section cited above as the LPA observed dry feces in R1's bathroom floor which posed a potential health and safety or personal rights risk to persons in care.

Official plan of correction

ED agrees to have all care staff and house keeping staff training on how to maintain bathrroms in a clean and sanitary condition. Submit to CCL by 7/24/25.

Deadline recorded: Jul 24, 2025. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87466

Regulation authority

CCR

What the official deficiency says

87466 Observation of the resident. ... When changes such as unusual weight gains or losses.. are observed, the licensee shall ensure that such changes are documented and brought to the attention of the resident's physician and the resident's responsible person, if any. This requirement is not met as evidenced by: Based on the information gathered via interviews and record review, although the facility’s staff documented R1's weight loss they did not address it with their PCP which posed a potential health and safety risk to persons in care.

Official plan of correction

Business Office Director agreed to provide an in service to staff related to observation of the resident and addressing changes observed to PCP and resident's responsible party. Proof of training will be sent to CCL by POC due date of 06/05/25.

Deadline recorded: Jun 5, 2025. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87464(f)(4)

Regulation authority

CCR

What the official deficiency says

Observation of the Resident:The licensee shall ensure that residents are regularly observed for changes in physical, mental, emotional and social functioning and that appropriate assistance is provided when such observation reveals unmet needs. This requirement is not met as evidenced by: Based on the investigation, the licensee did not comply with the section cited above as staff and file review revealed R1 was observed to be declining, and wondering into other residents rooms which posed a potential health and safety risk to residents in care.

Official plan of correction

Current Executive Director reported that the facility residents are observed and monitored regularly and any significant change is reported accordingly. Will Submit a written self certification of understanding the regulation cited and their plan to ensure future compliance. Will submit Statement by 1/24/25.

Deadline recorded: Jan 24, 2025. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87468.1(a)(1)

Regulation authority

CCR

What the official deficiency says

Personal Rights. Residents in all residential care facilities for the elderly shall have all of the following personal rights: To be accorded dignity in their personal relationships with staff,. This requirement was not met as evidenced by: Based on interviews, the licensee did not comply with the section cited above when 6 out of 10 staff are voicing concerns regarding the treatment of the residents by staff which poses an immediate personal rights risk to residents in care.

Official plan of correction

ED agreed to ensure all memory care staff attend a training focused on Resident Personal Rights. Facility will provide CCL with copy of training agenda as well as a sign in sheet for all staff who attended the training by 01/03/2025.

Deadline recorded: Jan 3, 2025. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87303(a)(1)

Regulation authority

CCR

What the official deficiency says

87303(a)(1) 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. (1) Floor surfaces in bath, laundry and kitchen areas shall be maintained in a clean, sanitary, and odorless condition. This requirement is not met as evidenced by: Based on photos and interviews, the licensee did not comply with the section cited above as R1 was left in their room overnight with fire-extinguisher powder all over the room which posed an immediate health and safety risk to persons in care.

Official plan of correction

ED agrees to submit plan on how they will ensure resident rooms are maintained in a clean and sanitary condition including during NOC shifts. Submit to CCL by 12/24/24.

Deadline recorded: Dec 24, 2024. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87705(f)(1)

Regulation authority

CCR

What the official deficiency says

87705(f)(1) Care of Persons with Dementia (f) The following shall be stored inaccessible to residents with dementia: (1) Knives, matches, firearms, tools and other items that could constitute a danger to the resident(s). This requirement is not met as evidenced by: Based on interviews and observation, the licensee did not comply with the section cited above, as R1 had access to fire extinguisher, despite staff knowing that grabbing the fire extinguisher was a known behavior of R1, which posed a potential safety risk to persons in care.

Official plan of correction

ED agrees to submit a plan on how they will ensure items that could constitute a danger to the resident(s) will be stored inaccessible to residents with dementia.

Deadline recorded: Dec 27, 2024. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87468.1(a)(8)

Regulation authority

CCR

What the official deficiency says

Personal Rights of Residents(a) Residents in all residential care facilities for the elderly...following personal rights: (8) To have their representatives regularly informed by the licensee of activities related to care or services...This requirement is not met as evidenced by: Based on record review and interviews, licensee did not comply with the above section by failing to inform R1 Responsible party of any change in condition or care needs related to R1, which is a potential

Official plan of correction

Licensee agreed to inform responsible pary of any change of condition for all resident in care. Licensee will submit a statement of understanding of regulation cited by POC due date.

Deadline recorded: Oct 11, 2024. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87211(a)(1)

Regulation authority

CCR

What the official deficiency says

Reporting Requirements: (a) Each licensee shall... reports as the Department may require,...(1)A written report shall be submitted... person responsible...This requirement is not met as evidenced by: Based on interviews and record review, licensee did not comply with the above section by failing to report incidents to the Department and the responsible party involving R1, which is a potential personal rights risk to residents in care.

Official plan of correction

Licensee agreed to submit an incident report each time an event involving residents or staff occurs to CCL and responsible parties. Licensee will submit a statement of understanding of regulation cited by POC due date.

Deadline recorded: Oct 11, 2024. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87309(a)

Regulation authority

CCR

What the official deficiency says

(a) Disinfectants, cleaning solutions, poisons, firearms and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients. This requirement is not met as evidenced by: Deficient Practice Statement Based on observation, the licensee did not comply with the section cited above as four out of ten locked resident rooms had disinfectants and or cleaning solutions available within those residents rooms, which poses an immediate health and safety risk to persons in care.

Official plan of correction

POC Due Date: 10/25/2023 Plan of Correction Administrator immediately removed the items from the rooms and agreed to submit a plan to CCL on how they will ensure all rooms don't have disinfectants and cleaning solutions by 10/25/23.

Official classification

Type A

Official code

87412(a)(13)(B)

Regulation authority

CCR

What the official deficiency says

(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information: (13) For employees that are required to be fingerprinted pursuant to Section 87355, Criminal Record Clearance: (B) Documentation of either a criminal record clearance or a criminal record exemption as required by Section 87355(e). This requirement is not met as evidenced by: Deficient Practice Statement Based on record review, the licensee did not comply with the section cited above as one staff did not have a criminal record clearance, which poses an immediate health and safety risk to persons in care.

Official plan of correction

POC Due Date: 10/24/2023 Plan of Correction Administrator immediately a took the 1 staff without criminal record clearance off the schedule. POC is cleared during the visit.

Official classification

Type B

Official code

87468.1(a)(1)

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:(1) To be accorded dignity in their personal relationships with staff, residents, and other persons. This requirement is not met as evidenced by: Based on interviews with witnesses, staff and management, the licensee did not comply with the section cited above. Staff were observed on their personal phones rather than attending to residents, which poses a potential health and safety risk to residents in care.

Official plan of correction

Licensee will train all staff on expectations of providing care and supervision to residents and not allowing personal distractions such as purusing their personal cell phones while at work. Licensee will provide evidence of training to CCL on or before 5/11/2023.

Deadline recorded: May 11, 2023. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87211(a)(1)(D)

Regulation authority

CCR

What the official deficiency says

87211 Reporting Requirements (a) Each licensee shall furnish to the licensing agency such reports as the Department may require, including, but not limited to, the following:(1) A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence...(D) Any incident which threatens the welfare, safety or health of any resident... This requirement was not met as evidenced by: Based on records review, R1 had multiple falls in July 2022 and was taken for medical care twice due to the falls, however these falls were not reported to CCL, which poses a potential health and safety risk to residents in care.

Official plan of correction

Licensee will train staff on reporting requirements and provide evidence of training to CCL on or before 5/11/2023.

Deadline recorded: May 11, 2023. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87625(b)(3)

Regulation authority

CCR

What the official deficiency says

87625(b)(3) Managed Incontinence...the licensee shall be responsible for the following: Ensuring that incontinent residents are kept clean and dry and that the facility remains free of odors from incontinence. This requirement is not met as evidenced by: Based on interviews, record review and observation, the licensee did not comply with the section cited above, as they did not ensure residents’ incontinence was properly managed, which poses an immediate health and safety risk to residents in care.

Official plan of correction

The Administrator agreed to do the following: 1. Submit a Plan of Action, indicating how staff will care for residents with bladder and bowel incontinence and how the facility will manage R2’s room cleanings. Submit plan of action no later than 3/6/2023. 2. Hold an in-service training with all staff regarding regulation 87625 Managed Incontinence. Submit sign-in sheet of completed training within the next seven days, but no later than 3/11/2023.

Deadline recorded: Mar 4, 2023. 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)(2) 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 is not met as evidenced by: Based on record review and interviews, the licensee did not comply with the section cited above the staff did not respond to R1 and R2's calls for assistance in a timely manner, which poses a potential personal risk to persons in care.

Official plan of correction

The Memory Care Director agreed to the following: 1. Review policies and procedures around responding to pendants. Send sign-in sheet to CCL no later than 2/24/2023.

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

Official classification

Type B

Official code

87468.1(a)(3)

Regulation authority

CCR

What the official deficiency says

87468.1(a)(3) Personal Rights of Residents in All Facilities. Residents ... shall have all of the following personal rights: To be free from punishment, humiliation, intimidation, abuse, or other actions of a punitive nature ... This requirement is not met as evidenced by: Based on interviews and records review, the licensee did not comply with the section cited above, as S1 restricted R1's movement by pressing their body against R1, which poses a potential personal rights risk to residents in care.

Official plan of correction

The Executive Director has agreed to do the following: 1. Management will complete an in-service training with staff, speaking to the approved guidelines staff will implement in supporting challenging behavior. The first round of training must take place in the next two days, with all staff having received the in-service training by 2/24/2023. Submit sign-in sheet and supporting documents to CCLD.

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

Official classification

Type A

Official code

87464(f)(1)

Regulation authority

CCR

What the official deficiency says

87464(f)(1) Basic Services. (f) Basic services shall at a minimum include: (1) 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 evidenced by: Based on interviews and records review, the licensee did not comply with the section cited above. Staff did not supervise R1 which resulted in R1’s fall sustaining a fracture of the right humerus and bruise of the right eye, which posed an immediate health and safety risk to residents in care.

Official plan of correction

Licensee will submit a plan how they will ensure appropriate resident care and supervision to residents is met. Submit to CCL by due date

Deadline recorded: Feb 10, 2023. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87608(a)(5)(B)

Regulation authority

CCR

What the official deficiency says

87608 Postural Supports (a) Based on the individual's preadmission appraisal, and subsequent changes to that appraisal, the facility shall provide assistance and care for the resident in those activities of daily living which the resident is unable to do for himself/herself. Postural supports may be used under the following conditions.(5)Under no circumstances shall postural supports include tying, depriving, or limiting the use of a resident's hands or feet.(B) Bed rails that extend the entire length of the bed are prohibited except for residents who are currently receiving hospice care and have a hospice care plan that specifies the need for full bed rails.

Official plan of correction

Licensee will submit a written action plan regarding proper use of bed rails and other postural supports to CCL by 12/02/2022. Based on interviews and records review, the licensee did not comply with the section cited above. Staff used a full length wooden backrest in place of full bed rails prior to R1 being placed on hospice which resulted in R1 sustaining multiple bruises, which posed an immediate health and safety risk to residents in care.

Deadline recorded: Dec 2, 2022. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87464(f)(1)

Regulation authority

CCR

What the official deficiency says

87464(f)(1) Basic Services. (f) Basic services shall at a minimum include: (1) 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 evidenced by: Based on interviews and records review, the licensee did not comply with the section cited above. Facility did not make use of fall precautions for R1 which resulted in R1 sustaining fall from bed and fracturing right wrist, which posed an immediate health and safety risk to residents in care.

Official plan of correction

Licensee will submit a written action plan regarding proper resident care and supervision to CCL by 12/02/2022. A civil penalty of $500 was assessed.

Deadline recorded: Dec 2, 2022. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87303(e)(2)

Regulation authority

CCR

What the official deficiency says

(e) Water supplies and plumbing fixtures shall be maintained as follows: (2) Faucets used by residents for personal care such as shaving and grooming shall deliver hot water. Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degree F (41 degrees C) and not more than 120 degree F (49 degrees C). This requirement is not met as evidenced by: Deficient Practice Statement Based on observation, the licensee did not comply with the section cited above in 4 (four) of 10 (ten) water temperature readings taken throughout the building were above the required range reading at 121.7, 123.8, 124.4, and 123.0 degrees Fahrenheit, which poses an immediate safety risk to persons in care.

Official plan of correction

POC Due Date: 11/07/2022 Plan of Correction Executive Director contacted the Maintenance Department, who is adjusting the water temperature today. Water temperatures will be taken daily for a week, recorded on a log and sent to LPA by POC due date.

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 This requirement is not met as evidenced by: Deficient Practice Statement Based on interview and record review, the licensee did not comply with the section cited above as Staff #1 (S1) has been employed and working in the facility since 11/10/2021 and S1's fingerprint clearance was not associated to the facility, which poses an immediate safety risk to persons in care.

Official plan of correction

POC Due Date: 10/27/2022 Plan of Correction During today's visit, Executive Director provided LPA with the transfer form and identification for S1 and LPA was able to transfer the employee's clearance in Guardian. POC cleared.

Official classification

Type A

Official code

87468.1(a)(3)

Regulation authority

CCR

What the official deficiency says

87468.1 Personal Rights of Residents in All Facilities (a)(3) To be free from punishment...or interfering with daily living functions such as eating, sleeping, or elimination. This requirement is not met as evidenced by: Based on interview and record review, the licensee did not comply with the above section, as staff are instructed to wake residents beginning at 4:00AM, which poses an immediate personal rights risk to residents in care.

Official plan of correction

Exectutive Director agreed to no longer wake residents from sleep, unless requested in writing by the resident or their responsible person(s). Staff will be trained on resident personal rights section 87468.1. Proof of training will be sent to CCL by 10/17/2022.

Deadline recorded: Oct 10, 2022. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87468.2(a)(10)

Regulation authority

CCR

What the official deficiency says

87468.2 Additional Personal Rights of Residents in Privately Operated Facilities. The licensee shall post the telephone numbers and addresses for the local offices of the ...ombudsman program... conspicuously in the facility foyer, lobby, residents’ activity room, or other location easily accessible to residents This requirement is not met as evidenced by: Based on observation, the licensee did not comply with the section cited above, as the Ombudsman poster was not observed in the memory care unit where memory care residents would be able to observe the poster, which poses a potential health and safety risk to residents in care.

Official plan of correction

Licensee will ensure there is an Ombudsman poster in the memory care unit and provide evidence of the posting to CCL on or before 07/08/2022.

Deadline recorded: Jul 8, 2022. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87705(f)(1)

Regulation authority

CCR

What the official deficiency says

87705 Care of Persons with Dementia(f)(1) The following shall be stored inaccessible to residents with dementia: Knives, matches, firearms, tools and other items that could constitute a danger to the resident(s). This requirement is not met as evidenced by: Based on LPA's observations and record review, the licensee did not comply with the section cited above as S1's medication was observed accessible to residents which poses an immediate health risk to persons in care.

Official plan of correction

Staff locked S1's office door during facility visit. Staff stated that they will provide documentation of scheduled staff training regarding regulation 87705(f)(1) to CCL by 4/15/22.

Deadline recorded: Apr 15, 2022. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87705(f)(2)

Regulation authority

CCR

What the official deficiency says

87705 Care of Persons with Dementia (f)(2) The following shall be stored inaccessible to residents with dementia: Over-the-counter medication, nutritional supplements or vitamins, alcohol, cigarettes, and toxic substances such as certain plants, gardening supplies, cleaning supplies and disinfectants. This requirement is not met as evidenced by: Based on LPA's observations and record review, the licensee did not comply with the section cited above as toxic substances were observed accessible to residents which poses an immediate health risk to persons in care.

Official plan of correction

Staff locked S1's office door and mechanical room door during facility visit. Staff stated that they will provide documentation of scheduled staff training regarding regulation 87705(f)(2) to CCL by 4/15/22.

Deadline recorded: Apr 15, 2022. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

1569.695(c)

Regulation authority

HSC

What the official deficiency says

1569.695 Emergency Plans (c) A facility shall conduct a drill at least quarterly for each shift. The type of emergency covered in a drill shall vary from quarter to quarter, taking into account different emergency scenarios. An actual evacuation of residents is not required during a drill. While a facility may provide an... This requirement is not met as evidenced by: Based on interview and record review, the licensee did not comply with the section cited above as quarterly disaster drills were not documented for each shift which posed a potential safety risk to persons in care.

Official plan of correction

Staff stated that they will provide documentation of quarterly disaster plans for each shift to CCL by 4/25/22.

Deadline recorded: Apr 25, 2022. 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

87464 Basic services (f)(1)(c) " Care and supervision " means the facility assumes responsibility for, or provides or promises to provide in the future, ongoing assistance with activities of daily living without which the resident’s physical health, mental health, safety, or welfare would be endangered. This requirement is not met as evidenced by: Based on interviews and record review, the licensee did not comply with the section cited above as R1 left the facility unassisted which poses an immediate health and safety risk to persons in care.

Official plan of correction

Administrator stated that a wanderguard was placed on R1 and family members will be notified in writing tomorrow not to let anyone follow them out of the memory care area. Administrator stated that they will provide documentation of staff training regarding safety and elopement protocols to CCL by 12/3/21.

Deadline recorded: Nov 30, 2021. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87705(f)(2)

Regulation authority

CCR

What the official deficiency says

87705 Care of Persons with Dementia (f)(2) The following shall be stored inaccessible to residents with dementia: Over-the-counter medication, nutritional supplements or vitamins, alcohol, cigarettes, and toxic substances such as certain plants, gardening supplies, cleaning supplies and disinfectants. This requirement is not met as evidenced by: Based on LPA's observations, the licensee did not comply with the section cited above as laundry detergent was accessible to residents which poses an immediate health and safety risk to persons in care.

Official plan of correction

Administrator placed laundry detergent in a locked laundry room during facility visit. Administrator stated that they will notify all residents that they cannot leave laundry detergent and supplies in the laundry room.

Deadline recorded: Nov 30, 2021. A deadline is not proof that correction was completed.