195850209-6-20-2024-29-AS-DPEA-D6MLC6-20240627083745

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 195850209
Report Date: 06/20/2024
Date Signed: 06/20/2024 10:47:35 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, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

This is an official report of an unannounced visit/investigation of a complaint received in our office on
10/28/2022 and conducted by Evaluator Brian Balisi

COMPLAINT CONTROL NUMBER: 29-AS-20221028111033

FACILITY NAME:	OAKMONT OF AGOURA HILLS		FACILITY NUMBER:	195850209
ADMINISTRATOR:	SAHAR MOSALLA		FACILITY TYPE:	740
ADDRESS:	29353 CANWOOD STREET		TELEPHONE:	(747) 755-5700
CITY:	AGOURA HILLS	STATE: CA	ZIP CODE:	91301
CAPACITY:	0	CENSUS: 0	DATE:	06/20/2024
		UNANNOUNCED	TIME BEGAN:	09:30 AM
MET WITH:	Lily Chaparyan - Executive Director		TIME COMPLETED:	10:45 AM

ALLEGATION(S):

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Resident sustained pressure injuries while in care

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Brian Balisi conducted a subsequent complaint visit to deliver final findings for the allegation listed above. During today’s visit, LPA met with Lily Chaparyan and explained the reason for the visit.

On 11/04/2022, from 9:00 a.m. – 3:00 p.m., LPA initiated an unannounced complaint investigation for the allegations listed above. During the visit, LPA toured the physical plant, interviewed staff, residents and reviewed and obtained pertinent documents relevant to the investigation. On 08/14/2023, from 10:00 a.m. – 3:00 p.m., LPA conducted a subsequent complaint visit. During the visit, LPA toured physical plant, interviewed staff, and reviewed and obtained copies of additional documentation relevant to the investigation. Over the course of the investigation, LPA interviewed various family members, acquaintances of Resident #1 (R1). On 04/18/2024, LPA reviewed R1’s medical records from Los Robles Hospital.

Continued on 9099-C

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Desaree Perera	TELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Brian Balisi	TELEPHONE: (818) 421-9171
LICENSING EVALUATOR SIGNATURE:	DATE: 06/20/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/20/2024

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 5

Control Number 29-AS-20221028111033

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: OAKMONT OF AGOURA HILLS	FACILITY NUMBER: 195850209
	VISIT DATE: 06/20/2024

NARRATIVE

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It was reported that Resident # (R1) sustained pressure injuries while in care, as R1’s pressure injury worsened due to staff neglect/lack of care. Information gathered during the course of the investigation reflected that staff observed a sore on the lower back area of R1 on 10/01/2022. The area affected was noted to be red, approximately less than a size of a quarter. Facility staff notified R1’s Primary Care Physician (PCP) via fax and requested an order for Calmoseptine cream. On 10/03/2022, facility staff again faxed R1’s PCP informing of R1’s sore and requested a referral for Home Health Agency (HHA) along with an order for Calmoseptine cream. Facility received approval for HHA and the cream from PCP on 10/12/2022. There was no documentation to support that facility staff attempted to contact R1’s PCP via phone. R1’s Medication Administration Records (MAR) revealed Calmoseptine was administered by facility staff as prescribed from 10/12/2022 to 10/25/2022. On 10/26/2022, HHA attempted to assess R1; however, R1 was already transferred to Los Robles Hospital, due to throat pain and pain at the site of wound on buttocks. Hospital records reviewed reflected that upon admission to the hospital, R1 was diagnosed with a pressure injury of skin of sacral region with an unspecified injury stage. Additionally, there was no documentation to support that the facility staff attempted to contact R1’s PCP regarding the worsening pressure injury or obtain any medical attention for R1 prior to R1’s family transporting R1 to the hospital.

Based on the information gathered, the Department has sufficient evidence to determine that facility staff did not take all necessary steps to ensure R1 received the appropriate care upon staff initially discovering the pressure injury on R1’s lower back. Therefore, the above allegation is deemed SUBSTANTIATED at this time.

Pursuant to Title 22, California Code of Regulations, the following deficiencies are cited (refer to LIC 9099-D).

Exit interview conducted, appeal rights discussed, and a copy of this report issued.

SUPERVISOR'S NAME: Desaree Perera	TELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Brian Balisi	TELEPHONE: (818) 421-9171
LICENSING EVALUATOR SIGNATURE:	DATE: 06/20/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/20/2024

LIC9099 (FAS) - (06/04)

Page: 2 of 5

Control Number 29-AS-20221028111033

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: OAKMONT OF AGOURA HILLS	FACILITY NUMBER: 195850209
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 06/20/2024

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 06/20/2024 Section Cited CCR 87631(a)(3)(A)	1 2 3 4 5 6 7	Except as specified in Section 87611(a), the licensee shall be permitted to accept or retain a resident who has a healing wound under the following circumstances...physician or an appropriately skilled professional. This requirement is not met as evidenced by:	1 2 3 4 5 6 7	Faciltiy is closed.
	8 9 10 11 12 13 14	Based on interviews and record review, licensee did not comply with the above section by not obtaining appropriate care for R1 after observing a sore on R1’s back, which an immediate health and safety concern to resident in care.	8 9 10 11 12 13 14
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

SUPERVISOR'S NAME: Desaree Perera	TELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Brian Balisi	TELEPHONE: (818) 421-9171
LICENSING EVALUATOR SIGNATURE:	DATE: 06/20/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/20/2024

LIC9099 (FAS) - (06/04)

Page: 3 of 5

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

This is an official report of an unannounced visit/investigation of a complaint received in our office on
10/28/2022 and conducted by Evaluator Brian Balisi

COMPLAINT CONTROL NUMBER: 29-AS-20221028111033

FACILITY NAME:	OAKMONT OF AGOURA HILLS		FACILITY NUMBER:	195850209
ADMINISTRATOR:	SAHAR MOSALLA		FACILITY TYPE:	740
ADDRESS:	29353 CANWOOD STREET		TELEPHONE:	(747) 755-5700
CITY:	AGOURA HILLS	STATE: CA	ZIP CODE:	91301
CAPACITY:	0	CENSUS: 0	DATE:	06/20/2024
		UNANNOUNCED	TIME BEGAN:	09:30 AM
MET WITH:	Lily Chaparyan - Executive Director		TIME COMPLETED:	10:45 AM

ALLEGATION(S):

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Facility staff did not notify authorized representative of change in condition

Facility staff did not meet resident’s oral hygiene needs

INVESTIGATION FINDINGS:

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Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Desaree Perera	TELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Brian Balisi	TELEPHONE: (818) 421-9171
LICENSING EVALUATOR SIGNATURE:	DATE: 06/20/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/20/2024

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 5

Control Number 29-AS-20221028111033

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: OAKMONT OF AGOURA HILLS	FACILITY NUMBER: 195850209
	VISIT DATE: 06/20/2024

NARRATIVE

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It was alleged that facility staff did not notify R1’s authorized representative of change in condition. It was further reported that the facility did not inform the authorized representative that R1 had a pressure injury, was not eating, had swallowing difficulties and had lost weight. Information gathered during the course of the investigation reflected that R1 was initially admitted to the Assisted Living (AL) portion of the facility on 09/05/2022. However, due to R1’s decline facility conducted a reappraisal on 10/25/2022 and it was determined that R1 needed a high level of care and would be better suited in Memory Care (MC). Additionally, records and interviews further reflected that the facility also conducted a reappraisal on 09/20/2022 due to R1’s decline. Interviews conducted also reflected that R1’s Power of Attorney (POA)/Responsible Party (RP), was aware of R1’s decline and was notified of the pressure injury. Moreover, it was revealed that the facility attempted to discuss the reappraisals with R1’s authorized representative however, was unable due to the authorized representative rescheduling the meetings. Based on the information obtained during the investigation, the Department does not have sufficient evidence to corroborate the allegation. 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, therefore the above allegation “staff did not notify R1’s authorized representative of change in condition” is deemed UNSUBSTANTIATED at this time.

It was alleged that the facility staff did not meet resident’s oral hygiene needs, as it was alleged that staff neglected to assist R1 with brushing their teeth resulting in poor oral hygiene. Interviews conducted and records reviewed revealed that upon admittance R1 did not need assistance with brushing their teeth. However, as R1’s health declined R1 needed assistance with brushing R1’s teeth. Per interviews with staff, staff would assist R1 with brushing their teeth even though, R1 would sometimes refuse. Information also obtained during the course of the investigation reflected that during admission to the facility R1’s teeth were already slow declining. Based on the information obtained during the investigation, the Department does not have sufficient evidence to corroborate the allegation. 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, therefore the above allegation “facility staff did not meet resident’s oral hygiene needs” is deemed UNSUBSTANTIATED at this time.

Exit interview conducted/No citations issued/ A copy of Report provided.

SUPERVISOR'S NAME: Desaree Perera	TELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Brian Balisi	TELEPHONE: (818) 421-9171
LICENSING EVALUATOR SIGNATURE:	DATE: 06/20/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/20/2024

LIC9099 (FAS) - (06/04)

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