195850209-6-2-2023-29-AS-DPEA-CT6SZX-20230626141951

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 195850209
Report Date: 06/02/2023
Date Signed: 06/02/2023 02:41:34 PM

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
03/14/2023 and conducted by Evaluator Brian Balisi

COMPLAINT CONTROL NUMBER: 29-AS-20230314152608

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:	102	CENSUS: 66	DATE:	06/02/2023
		UNANNOUNCED	TIME BEGAN:	09:00 AM
MET WITH:	Ivette Rios - Regional Memory Care Specialist		TIME COMPLETED:	11:00 AM

ALLEGATION(S):

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Staff prevented resident from having visitors

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Brian Balisi conducted an unannounced complaint visit to investigate the allegation listed above. Upon arrival LPA met with Regiononal Memory Care Specialist Ivette Rios and explained the reason for the visit.

On 03/17/2023, between 9:30am - 3pm, LPA conducted the initial 10-day complaint visit. LPA conducted physical plant, reviewed and obtained pertinent documents relevant to the investigation as well as interviewed staff, resident and families of residents in care. Today LPA conducted physical plant and reviewed and obtained additional documents relevant to the investigation.

It was reported that staff prevented resident from having visitors, as it was alleged on 02/17/2023, a visitor attempted to visit Resident 1 (R1), but was asked to exit the facility. Interviews conducted and records review revealed staff were provided with a list of individuals that were not allowed to visit R1.

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: 06/02/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/02/2023

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 29-AS-20230314152608

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: 06/02/2023

NARRATIVE

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Continued from 9099

Interviews with staff further revealed that a visitor did in fact attempt to visit R1 on 02/17/2023, but was escorted out, as staff were following the documented instructions provided by R1's POA, which stated to restrict access to R1 for specific individuals. LPA did not observe any restraining orders kept in R1's file at this time. Based on information gathered during this and previous visits, the department has sufficient evidence to determine that staff prevented visitors from visiting R1. Therefore, the allegation listed above has been deemed Substantiated at this time.

The following deficiencies were observed (See LIC 9099-D.) and cited from the California Code of Regulations, Title 22 and California Health and Safety Code. Failure to correct the deficiencies may result in civil penalties. Exit interview conducted.

A copy of the report and appeal rights were provided.

SUPERVISOR'S NAME: Desaree Perera	TELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Brian Balisi	TELEPHONE: (818) 421-9171
LICENSING EVALUATOR SIGNATURE:	DATE: 06/02/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/02/2023

LIC9099 (FAS) - (06/04)

Page: 2 of 3

Control Number 29-AS-20230314152608

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: 06/02/2023

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 06/09/2023 Section Cited CCR 87468.1(a)(11)	1 2 3 4 5 6 7	87468.1(a)(11) To have their visitors, including ombudspersons and advocacy representatives, permitted to visit privately... the rights of other residents are not infringed upon. This requirement is not met as evidenced by:	1 2 3 4 5 6 7	Licensee agreed to submit a statement of understanding of regulation 87468.1(a)(11) and submit to CCLD via email by COB 06/09/2023
	8 9 10 11 12 13 14	Based on interviews and record review, the licensee did not comply with the section cited above as staff prevented R1 from having visitors which poses as a potential health, safety or personal rights risk to persons 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: 06/02/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/02/2023

LIC9099 (FAS) - (06/04)

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