019200889-11-19-2020-15-AS-KHOS-BVWK44-20201202063340

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 019200889
Report Date: 11/19/2020
Date Signed: 11/19/2020 01:47:39 PM

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
07/13/2020 and conducted by Evaluator Celia Phomphachanh

COMPLAINT CONTROL NUMBER: 15-AS-20200713142117

FACILITY NAME:	OAKMONT OF MARINER POINT		FACILITY NUMBER:	019200889
ADMINISTRATOR:	WONG, ELAINE		FACILITY TYPE:	740
ADDRESS:	2400 MARINER SQUARE DRIVE		TELEPHONE:	(707) 535-3200
CITY:	ALAMEDA	STATE: CA	ZIP CODE:	94501
CAPACITY:	80	CENSUS: 63	DATE:	11/19/2020
		UNANNOUNCED	TIME BEGAN:	12:30 PM
MET WITH:	Avon Nguyen, Executive Director		TIME COMPLETED:	01:45 PM

ALLEGATION(S):

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Facility staff did not call 9-1-1 for injured resident.
Facilty staff did not apply first aid to resident after unwitnessed fall.

INVESTIGATION FINDINGS:

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On Thursday, November 19, 2020, Licensing Program Analyst (LPA) C. Phomphachanh call facility to deliver the finding for the above allegations. LPA spoke with new Executive Director, Avon Nguyen. Due to the Executive Order, Shelter in Place, set forth by the Governor, LPA was not able to deliver the findings in person.

During the course of the investigation, LPA conducted interview with Reporting Party (RP),witnesses (W1, W2, and W3), staff (S1-S6) and reviewed pertinent documents.

For the allegation, facility staff did no call 9-1-1 for injured resident. RP stated that none of the facility staff called 9-1-1 for an unwitnessed fall for the resident. RP stated that W2 called 9-1-1 while RP and W3 were assisting with R1. W1 went to knock on the facility to inform staff that R1 fell near the building.

Continuation on LIC 9099 C - Page 1 of 2 Complaint Investigation

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Julio Montes	TELEPHONE: (510) 286-0518
LICENSING EVALUATOR NAME: Celia Phomphachanh	TELEPHONE: (510)286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 11/19/2020

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/19/2020

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 2

Control Number 15-AS-20200713142117

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 MARINER POINT	FACILITY NUMBER: 019200889
	VISIT DATE: 11/19/2020

NARRATIVE

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Page 2 of 2 Complaint Investigation

When LPA interviewed S2 and S3, S2 stated that S2 called 9-1-1 once S2 known of the fall from W1. S3 stated that once S3 known of the fall, S3 came down from the 3rd floor and instructed S2 to call 9-1-1. Therefore, it occurred to LPA that both W2 and S2 contacted 9-1-1. This allegation is unsubstantiated.

For the allegation, facility staff did not apply first aid to resident after witnessed fall. RP stated that W1, W2, and W3 saw R1 fall and immediately went to assist R1. W1 went to inform facility staff, W2 called 9-1-1 and W3 was attending to R1. When LPA interviewed S2, S2 stated that S2 immediately contact staff via walkie talkie when W1 informed S2. S3 came down and W3 was attending to R1. W3 instructed S3 to go get first aid items and other medical supplies to assist with R1. S3 went to get the items. Then, S4 and S5 arrived to the scene, W3 instructed S4 to get towels while S5 stayed to help W3 with R1. S5 stayed with W3 and R1 until paramedic arrived to the scene. Therefore, this allegation is unsubstantiated.

Based on interviews conducted and records reviewed, LPA determined the allegations to be unsubstantiated. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur.

Exit interview conducted with Executive Director, Avon Nguyen. Copy of report provide via PDF emailed.

SUPERVISOR'S NAME: Julio Montes	TELEPHONE: (510) 286-0518
LICENSING EVALUATOR NAME: Celia Phomphachanh	TELEPHONE: (510)286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 11/19/2020

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/19/2020

LIC9099 (FAS) - (06/04)

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