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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 092700750
Report Date: 04/08/2025
Date Signed: 04/08/2025 11:36:13 AM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
This is an official report of an unannounced visit/investigation of a complaint received in our office on
09/25/2024 and conducted by Evaluator Lavinia Muscan
COMPLAINT CONTROL NUMBER: 59-AS-20240925193249
FACILITY NAME:OAKMONT OF EL DORADO HILLSFACILITY NUMBER:
092700750
ADMINISTRATOR:GRAVELYN, LYDIAFACILITY TYPE:
740
ADDRESS:2020 TOWN CENTER WEST WAYTELEPHONE:
(916) 467-8330
CITY:EL DORADO HILLSSTATE: CAZIP CODE:
95762
CAPACITY:129CENSUS: 77DATE:
04/08/2025
UNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Administrator Chad RogersTIME COMPLETED:
11:45 AM
ALLEGATION(S):
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Staff did not provide adequate supervision resulting in resident sustaining a fracture while in care.
Staff did not prevent resident from suffering multiple falls while in care.
INVESTIGATION FINDINGS:
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On April 8, 2025, Licensing Program Analysts (LPAs) Lavinia Muscan and Talwinder Bains arrived at the facility unannounced to deliver complaint findings into the allegations listed above and met with Administrator Chad Rogers.

During the investigation, the Department conducted interviews and reviewed documentation pertinent to the investigation.

The results of the investigation are as follows:

**Report continued on 9099-C**
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Laura Munoz
LICENSING EVALUATOR NAME: Lavinia Muscan
LICENSING EVALUATOR SIGNATURE:

DATE: 04/08/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/08/2025
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 4
Control Number 59-AS-20240925193249
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME: OAKMONT OF EL DORADO HILLS
FACILITY NUMBER: 092700750
VISIT DATE: 04/08/2025
NARRATIVE
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Staff did not provide adequate supervision resulting in resident sustaining a fracture while in care.
Staff did not prevent resident from suffering multiple falls while in care.

On July 16, 2024, R1 sustained a fall in the facility. Hospital medical records stated that on July 16, 2024, R1 sustained a broken left collarbone. Hospital Doctor confirmed that R1’s CT scan of spine showed a “comminuted left clavicular head fracture.” Doctor stated that the injury was an acute injury and was consistent with someone sustaining a fall. R1 reported they were in their room walking with their walker alone when R1 sustained a fall. R1 remembers bleeding “a lot” from their head. R1 did not know where facility staff were at the time of R1’s fall. File review documents do not document a specific fall plan for R1. A review of R1’s file indicated the facility conducted (2) two Reassessments on R1. Initial assessment at time of move in dated March 1, 2023, and June 20, 2024 due to a change in condition. R1 Needs and Service plans indicated R1 requires a personalized interventions per fall management protocol however the facility was unable to provide documentation with the personalized interventions the facility put in place to assist for R1.

Facility staff interviewed reported that R1 sustained approximately 20 plus falls while at the facility. The facility did not have a clear plan in place to keep R1 from continuing to sustain these falls.
Previous Administrator Lydia Gravelyn and another staff stated they believed R1 required a higher level of care than the facility could provide. R1 would constantly refuse care and assistance from facility staff, yet the facility allowed R1 to continue constantly falling while at the facility. The medical records obtained support that R1 sustained multiple falls resulting in head injuries and a clavicle fracture. Each fall was a result of R1 attempting to do things on their own rather than requesting assistance from facility staff. Facility file review records document R1 sustained 15 falls between 3/9/2023 and 7/16/2024.

Facility failed to develop a personalized intervention plan as indicated in R1's needs and service plan resulting in R1 sustaining many falls at the facility including the fall R1 sustained on July 16, 2024, which caused R1 a serious injury. The above allegations are found to be SUBSTANTIATED. Per California Code of Regulations, Title 22 Division 6, Chapter 8, a deficiency is being cited on the attached 9099-D page. A civil penalty in the amount of $500 is assessed.

The licensee was informed during today’s visit that a civil penalty is under review and may be assessed at a future date according to Health and Safety Code §1569.49.


Exit interview conducted. Appeal rights provided. Report left with facility Administrator.
SUPERVISORS NAME: Laura Munoz
LICENSING EVALUATOR NAME: Lavinia Muscan
LICENSING EVALUATOR SIGNATURE:

DATE: 04/08/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/08/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 4
Control Number 59-AS-20240925193249
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: OAKMONT OF EL DORADO HILLS
FACILITY NUMBER: 092700750
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/08/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Request Denied
Type A
04/09/2025
Section Cited
CCR
87463
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Reappraisals
(i) When there is significant change in condition, as defined in Section 87101, Definitions, or once every 12 months, whichever occurs first, the licensee shall arrange an in-person or virtual meeting or conference call to share the reappraisal with the resident, the resident's representative, if applicable, and appropriate facility staff...
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The administrator agrees to write a plan of correction detailing how facility will address reassessments for resident’s who are documented fall risks. Additionally, the facility agrees to submit a plan on how staff will be trained and notified of resident’s who are fall risks and fall prevention protocols for each resident.
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This requirement was not met based on the facility failed to ensure reassessments were conducted due to R1’s change in conditions. Additionally, the facility failed to develop a personalized intervention plan as indicated in R1's needs and service plan. This posed an immediate Health and Safety risk to residents in care.
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Request Denied
Type A
04/09/2025
Section Cited
CCR
87468.2
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Additional Personal Rights of Residents in Privately Operated Facilities
(a) In addition to the rights listed in Section 87468.1, Personal Rights of Residents in All Facilities, residents in privately operated residential care facilities for the elderly shall have all of the following personal rights:
(4) 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.
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The administrator agrees to write a plan of corrections detailing how facility will address reassessments for resident’s who are documented fall risks.

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This requirement was not met based on facility failed to ensure staff were trained on a personalized fall protocols for R1. This posed an immediate Health and Safety risk to residents 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: Laura Munoz
LICENSING EVALUATOR NAME: Lavinia Muscan
LICENSING EVALUATOR SIGNATURE:

DATE: 04/08/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/08/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 4
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
This is an official report of an unannounced visit/investigation of a complaint received in our office on
09/25/2024 and conducted by Evaluator Lavinia Muscan
COMPLAINT CONTROL NUMBER: 59-AS-20240925193249

FACILITY NAME:OAKMONT OF EL DORADO HILLSFACILITY NUMBER:
092700750
ADMINISTRATOR:GRAVELYN, LYDIAFACILITY TYPE:
740
ADDRESS:2020 TOWN CENTER WEST WAYTELEPHONE:
(916) 467-8330
CITY:EL DORADO HILLSSTATE: CAZIP CODE:
95762
CAPACITY:129CENSUS: DATE:
04/08/2025
UNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Administrator Chad RogersTIME COMPLETED:
11:45 AM
ALLEGATION(S):
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Facility did not issue a refund to a resident in care.
INVESTIGATION FINDINGS:
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On April 8, 2025, Licensing Program Analysts (LPAs) Lavinia Muscan and Talwinder Bains arrived at the facility unannounced to deliver complaint findings into the allegations listed above and met with Administrator Chad Rogers.

During the investigation, the Department conducted interviews and reviewed documentation pertinent to the investigation.

The results of the investigation are as follows:
Facility did not issue a refund to a resident in care.
Based on record review and interview with Responsible Party, it was determined that facility issued a refund back to the responsible party, therefore the above allegation is UNFOUNDED.

Exit interview. Report left with Administrator.
Unfounded
Estimated Days of Completion:
SUPERVISORS NAME: Laura Munoz
LICENSING EVALUATOR NAME: Lavinia Muscan
LICENSING EVALUATOR SIGNATURE:

DATE: 04/08/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/08/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 4 of 4