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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 079201085
Report Date: 12/12/2024
Date Signed: 12/12/2024 11:46:37 AM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
This is an official report of an unannounced visit/investigation of a complaint received in our office on
12/06/2024 and conducted by Evaluator Daisy Panlilio
COMPLAINT CONTROL NUMBER: 15-AS-20241206113512
FACILITY NAME:OAKMONT OF CONCORDFACILITY NUMBER:
079201085
ADMINISTRATOR:SOR, KIM SFACILITY TYPE:
740
ADDRESS:1401 CIVIC COURTTELEPHONE:
(925) 798-4004
CITY:CONCORDSTATE: CAZIP CODE:
94520
CAPACITY:121CENSUS: 91DATE:
12/12/2024
UNANNOUNCEDTIME BEGAN:
11:22 AM
MET WITH:Kim Sor, Executive DirectorTIME COMPLETED:
12:15 PM
ALLEGATION(S):
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Staff did not ensure that resident had required oxygen administration
Staff mismanaged resident's medication
Staff did not ensure that medication was inacessible to others
INVESTIGATION FINDINGS:
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On 12/12/24 at 11AM, Licensing Program Analyst (LPA) D Panlilio conducted a subsequent complaint visit, met with executive director (ED), gathered information and delivered investigation findings to ED. LPA explained the purpose of the visit with ED.

On 12/06/24 at 3PM, LPA interviewed staff (ED, S1, S2) and obtained the following documents: Resident roster with contact information, Personnel record (LIC500), R1's admission agreement, Hospice care plan, Doctors’ orders, Centrally stored medications & medication administration records (MARs), visitors logs (10/28 to 10/31).

Continued on next page, LIC 9099-C
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Daisy Panlilio
LICENSING EVALUATOR SIGNATURE:

DATE: 12/12/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/12/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 6
Control Number 15-AS-20241206113512
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME: OAKMONT OF CONCORD
FACILITY NUMBER: 079201085
VISIT DATE: 12/12/2024
NARRATIVE
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Allegation: Staff did not ensure that resident had required oxygen administration
Investigation Finding: Substantiated
On 12/10/24 at 3:30PM, staff (S1, S2) confirmed with LPA that memory care hospice resident’s (R1) oxygen machine was turned off by S2 on 10/29/24 around 6:20PM because the machine emitted intermittent screeching sounds which agitated R1. S2 also stated that he/she removed R1’s oxygen mask and then left R1’s room that day. S1 stated that she was getting ready to go home around 6:30PM when she asked S2 how R1 was doing and S2 told her that he/she turned off R1’s oxygen machine and removed her oxygen mask. S2 stated she told S2 to call the hospice care team regarding the incident and immediately went to R1, turned the oxygen machine on and placed her oxygen mask on. Based on records review, interviews conducted, and observations made, the department has investigated the above allegation that staff did not ensure that resident had required oxygen administration. The preponderance of evidence standard has been met, therefore the above allegation was found to be substantiated.

Allegation: Staff mismanaged resident’s medication
Investigation Finding: Substantiated
On 12/10/24 at 4PM, staff (S1, S2) confirmed with LPA that hospice resident’s (R1) morphine medication was administered 2 hours late on 10/29/24. S2 stated he/she gave the morphine medication to S1 around 7PM instead of 5PM because he/she was waiting for R1’s medication dosage change orders which did not arrive on time. Review of R1’s medication administration records dated 10/29/24 showed R1’s morphine medication was to be administered every 4 hours as prescribed by the hospice care team for R1’s comfort care. Based on records review, interviews conducted, and observations made, the department has investigated the above allegation that staff mismanaged resident’s medication. The preponderance of evidence standard has been met, therefore the above allegation was found to be substantiated.

Continued on next page, LIC 9099-C pg1

SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Daisy Panlilio
LICENSING EVALUATOR SIGNATURE:

DATE: 12/12/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/12/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 6
Control Number 15-AS-20241206113512
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME: OAKMONT OF CONCORD
FACILITY NUMBER: 079201085
VISIT DATE: 12/12/2024
NARRATIVE
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Allegation: Staff did not ensure that medication was inaccessible to others
Investigation Finding: Substantiated
On 12/10/24 at 4PM, staff (S1) confirmed with LPA that on 10/29/24 around 6:40PM, hospice resident’s (R1) morphine medication was left unattended on hospice resident’s (R1) side table in the presence of R1’s family members. S1 stated that she left the unopened morphine medication in R1’s room temporarily so she can take an important phone call from R1’s hospice care team for advice regarding the temporary removal of R1’s oxygen mask and oxygen machine turnoff. Based on records review, interviews conducted, and observations made, the department has investigated the above allegation that staff did not ensure that medication was inaccessible to others. The preponderance of evidence standard has been met, therefore the above allegation was found to be substantiated.

Deficiencies are cited per Title 22 California Code of Regulations and listed on LIC9099D.

Failure to submit proof of correction (POC) by plan of correction due date and/or any repeat deficiencies within a 12-month period may result in civil penalties.

Exit interview conducted. Appeal Rights and a copy of this report provided.

SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Daisy Panlilio
LICENSING EVALUATOR SIGNATURE:

DATE: 12/12/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/12/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 6
Control Number 15-AS-20241206113512
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: OAKMONT OF CONCORD
FACILITY NUMBER: 079201085
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/12/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
12/30/2024
Section Cited
CCR
87633(d)
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The licensee shall ensure that the hospice care plan is current, accurately matches the services actually being provided, and that the client’s care needs are being met at all times.
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By POC due date, administrator agreed to submit to CCL completed in-service staff retraining certifications on the proper implementation of hospice care plans specific to the current and ongoing needs of the hospice resident in compliance with Title 22 Section 87633 regulations.
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This requirement was not met as evidenced by staff failing to ensure that hospice resident had required oxygen administration as prescribed by the hospice care team which posed a potential health & safety risk to resident in care.
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Type B
12/30/2024
Section Cited
CCR
87633(b)(2)
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A description of the services to be provided in the facility by the hospice agency including but not limited to the type and frequency of services to be provided.
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By POC due date, administrator agreed to submit to CCL completed in-service staff retraining certifications on hospice care plan implementation in compliance with Title 22 Section 87633 regulations.
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This requirement was not met as evidenced by staff failing to provide timely medication administration for comfort care which posed a potential health & safety risk to the hospice resident in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Daisy Panlilio
LICENSING EVALUATOR SIGNATURE:

DATE: 12/12/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/12/2024
LIC9099 (FAS) - (06/04)
Page: 4 of 6
Control Number 15-AS-20241206113512
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: OAKMONT OF CONCORD
FACILITY NUMBER: 079201085
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/12/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
12/30/2024
Section Cited
CCR
87633(k)
1
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3
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The licensee shall maintain a record of dosages of medications that are centrally stored for each resident receiving hospice services in the facility…
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By POC due date, administrator agreed to submit to CCL completed in-service staff retraining certifications on proper storage of controlled substances prior to being administered to the resident in compliance with Title 22 Section 87459 regulations.
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This requirement was not met as evidenced by staff failing to safely store a controlled substance which posed a potential health & safety risk to resident in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Daisy Panlilio
LICENSING EVALUATOR SIGNATURE:

DATE: 12/12/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/12/2024
LIC9099 (FAS) - (06/04)
Page: 5 of 6
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
This is an official report of an unannounced visit/investigation of a complaint received in our office on
12/06/2024 and conducted by Evaluator Daisy Panlilio
COMPLAINT CONTROL NUMBER: 15-AS-20241206113512

FACILITY NAME:OAKMONT OF CONCORDFACILITY NUMBER:
079201085
ADMINISTRATOR:SOR, KIM SFACILITY TYPE:
740
ADDRESS:1401 CIVIC COURTTELEPHONE:
(925) 798-4004
CITY:CONCORDSTATE: CAZIP CODE:
94520
CAPACITY:121CENSUS: 91DATE:
12/12/2024
UNANNOUNCEDTIME BEGAN:
11:22 AM
MET WITH:Kim Sor, Executive DirectorTIME COMPLETED:
12:15 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Staff do not prevent residents from wandering
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
On 12/12/24 at 11AM, Licensing Program Analyst (LPA) D Panlilio conducted a subsequent complaint visit, met with executive director (ED), gathered information and delivered investigation findings to ED. LPA explained the purpose of the visit with ED.

Allegation: Staff do not prevent residents from wandering
Investigation Finding: Unsubstantiated
During investigation, staff (ED) confirmed with LPA that during a final walk thru with R1’s responsible party (POA) on 10/31/24 another memory care resident (R2) was found inside R1’s room with the shower turned on in the bathroom. ED stated he immediately escorted R2 out of the room and had staff redirect her back to her bedroom. Based on records review, interviews conducted, and observations made, the department has investigated the above allegation that staff do not prevent residents from wandering. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did occur, therefore the allegation that staff do not prevent residents from wandering is unsubstantiated.
Exit interview conducted and a copy of this report provided.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Daisy Panlilio
LICENSING EVALUATOR SIGNATURE:

DATE: 12/12/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/12/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 6 of 6