197609905-12-16-2021-31-AS-EMIR-CFTV2S-20220628160331

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197609905
Report Date: 12/16/2021
Date Signed: 12/16/2021 05:35:29 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., STE. 250
WOODLAND HILLS, CA 91364

This is an official report of an unannounced visit/investigation of a complaint received in our office on
04/30/2021 and conducted by Evaluator Yelena Avetisyan

PUBLIC

COMPLAINT CONTROL NUMBER: 31-AS-20210430081216

FACILITY NAME:	OAKMONT OF SANTA CLARITA		FACILITY NUMBER:	197609905
ADMINISTRATOR:	GINA SALMAN		FACILITY TYPE:	740
ADDRESS:	28650 NEWHALL RANCH ROAD		TELEPHONE:	(661) 295-2025
CITY:	SANTA CLARITA	STATE: CA	ZIP CODE:	91355
CAPACITY:	0	CENSUS: 88	DATE:	12/16/2021
		UNANNOUNCED	TIME BEGAN:	09:10 AM
MET WITH:	Hugo Lemus and Tom Park.		TIME COMPLETED:	05:40 PM

ALLEGATION(S):

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Staff did not provide resident 1 (R1) services as documented in the care plan

INVESTIGATION FINDINGS:

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An unannounced subsequent complaint visit was conducted on this day by licensing program analyst (LPA) Yelena Avetisyan. Upon arrival LPA met with Health Services Director Hugo Lemus.

During this visit LPA conducted interview with Mr. Lemus, and facility staff, reviewed electronic file for resident 1 (R1). While reviewing R1's file LPA observed documents missing. A discussion was held with Mr. Lemus and the administrator Tom Park, who will locate the documents and send it to the LPA by COB 12/20/2021.

Regarding the allegation it was reported that facility staff did not provide R1 with shower assistance as documented in her care plan. During this visit while speaking with Mr. Lemus LPA was informed that after the resident tested positive for COVID, the staff did not provide the necessary showers. R1 received sponge baths. Mr. Lemus also informed the LPA that they did not complete shower logs due to the outbreak of COVID. Mr. Lemus does not recall if R1's responsible party was notified about the change in how hygiene care (Showers) were modified. Based on the information provided the allegation is substantiated at this time.
Exit interview conducted and copy of report emailed to the administrator and Mr. Lemus.

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Eva Miller	TELEPHONE: (818) 596-4373
LICENSING EVALUATOR NAME: Yelena Avetisyan	TELEPHONE: (818) 378-8120
LICENSING EVALUATOR SIGNATURE:	DATE: 12/16/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/16/2021

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 31-AS-20210430081216

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., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: OAKMONT OF SANTA CLARITA	FACILITY NUMBER: 197609905
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 12/16/2021

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 12/24/2021 Section Cited CCR 87464(f)(1)	1 2 3 4 5 6 7	(f) Basic services shall at a minimum include: (1) Care and supervision as defined in Section 87101(c)(3) and Health and Safety Code section 1569.2(c).	1 2 3 4 5 6 7	Licensee/administrator will notify the department what steps will be taken to ensure residents receive all services as documented in the care plans and/or agreed upon admission to the facility.
	8 9 10 11 12 13 14	Based on interview conducted the licensee did not comply with the cited section by not providing assistance with showers to resident 1 (R1) per care plan which posed potential personal rights risk to R1	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: Eva Miller	TELEPHONE: (818) 596-4373
LICENSING EVALUATOR NAME: Yelena Avetisyan	TELEPHONE: (818) 378-8120
LICENSING EVALUATOR SIGNATURE:	DATE: 12/16/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/16/2021

LIC9099 (FAS) - (06/04)

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