<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197609905
Report Date: 03/23/2022
Date Signed: 03/24/2022 10:05:14 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., 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 CLARITAFACILITY NUMBER:
197609905
ADMINISTRATOR:GINA SALMANFACILITY TYPE:
740
ADDRESS:28650 NEWHALL RANCH ROADTELEPHONE:
(661) 295-2025
CITY:SANTA CLARITASTATE: CAZIP CODE:
91355
CAPACITY:0CENSUS: 88DATE:
03/23/2022
UNANNOUNCEDTIME BEGAN:
08:30 AM
MET WITH:Hugo Lemus and Tom Park TIME COMPLETED:
07:05 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Questionable Death.
Licensee failed to obtain timely medical care for Resident 1 (R1)
Due to lack of proper care and supervision Resident 1 (R1) was dehydrated and developed UTI while living at the facility

INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
An unannounced subsequent complaint visit was conducted on this day by Licensing Program Analyst (LPA) Yelena Avetisyan. Upon arrival, the LPA met with Administrator Tom Park and Health Services Director Hugo Lemus.

Regarding the allegations listed above, it is being alleged that due to neglect and lack of care and supervision Resident 1 (R1) was dehydrated and developed a urinary tract infection (UTI). It is also being alleged that licensee failed to notify R1's physician and obtain timely medical care which contributed to the Residents Death.

These allegations were investigated by Olivia Spindola, Investigator with Community Care Licensing Division’s Investigations Branch.

On 05/03/2021, An initial 10 day complaint visit was conducted by LPA W. Smith. On that day, LPA Smith conducted a tour of the facility, spoke with the administrator, reviewed and obtained copies of documents related to the complaint investigations.
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Eva MillerTELEPHONE: (818) 596-4373
LICENSING EVALUATOR NAME: Yelena AvetisyanTELEPHONE: (818) 378-8120
LICENSING EVALUATOR SIGNATURE:

DATE: 03/23/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/23/2022
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 8
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
VISIT DATE: 03/23/2022
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
On various days from 5/17/2021 to 7/21/2021 Investigator Spindola conducted interviews with, facility staff, Health Services Director, family of R1. Additionally, on 6/6/2021 Investigator Spindola conducted review of R1’s medical records from Henry Mayo Hospital which were subpoenaed on 5/17/2021.

On various days from 12/21/2021 to 3/22/2022 additional staff interviews were conducted by LPA Avetisyan.

Information obtained during the course of the investigation revealed R1 tested for COVID19 on 12/11/2020 and positive test results were received on 12/14/2020 . R1 was hospitalized on 12/22/2020. According to the paramedics report facility staff reported that R1 gradually became weaker over the last 5 days, became aggressive, was not eating, drinking and refusing medications for the past 2 days. Staff interviews revealed that R1 began to deteriorate after testing positive for COVID19. Few days before hospitalization staff reported resident became weaker, laid in bed in 1 position, refused to eat or drink. The staff would attempt to give R1 water and/or ensure however the liquid would dribble out of R1’s mouth. Upon admission to the hospital R1 was diagnosed with COVID19, Viral Pneumonia, Bacterial pneumonia, Dehydration, Urogenital Candidiasis (UTI), Acute Encephalopathy. R1 passed away at the hospital on 12/28/2020.

Investigation also revealed that R1’s physician was not notified when R1 tested positive for COVID19, failed to notify the physician when there were changes in R1’s condition and waited approximately 2 to 5 days before obtaining medical care for R1.

Based on the information obtained during the course of the investigation, Investigator Spindola determined there is sufficient evidence to support the allegations; therefore, the allegations of Questionable Death, Licensee failed to obtain timely medical care for Resident 1 (R1) and Due to lack of proper care and supervision Resident 1 (R1) was dehydrated and developed UTI while living at the facility are Substantiated at this time.



Per California Code of Regulations (CCR), Title 22, see LIC 9099-D for deficiencies cited. An immediate civil penalty of $500 is also assessed. The licensee was informed that additional civil penalty might be assessed based on the Health and Safety Code 1569,49(e) or (f), or 1548(e) or (f), 1568.0822(e) or (f).

Exit Interview Conducted / Appeal Rights Discussed / A Copy of the Report Issued.

SUPERVISOR'S NAME: Eva MillerTELEPHONE: (818) 596-4373
LICENSING EVALUATOR NAME: Yelena AvetisyanTELEPHONE: (818) 378-8120
LICENSING EVALUATOR SIGNATURE:

DATE: 03/23/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/23/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 8
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: 03/23/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Request Denied
Type A
03/25/2022
Section Cited
CCR
87466
1
2
3
4
5
6
7
87466 Observation of the Resident. The licensee shall ensure that residents are regularly observed for changes in physical, mental, emotional and social functioning and that appropriate assistance is provided when such observation reveals unmet needs.
This requirement was not met as evidenced by:
1
2
3
4
5
6
7
The Administrator has agreed to do the following:
1. Develop and Submit facility protocol, which details how care staff are instructed to identify and document any changes in resident condition and what follow up actions will be taken and by whom Submit to CCL by 3/25/2022.
8
9
10
11
12
13
14
Based on the investigation, the licensee did not comply with the section cited, as the facility staff did not document or report R1 COVID Positive test result and change in condition to R1’s physician, or R1’s responsible party, which posed an immediate health and safety risk to R1.
8
9
10
11
12
13
14
2. Schedule an in-service training with care staff including agency staff, ensuring that staff are trained on the facility protocol as it pertains to the observation of the resident. Submit the sign-in sheet(s) to CCL by 5/5/2022.
Request Denied
Type A
03/25/2022
Section Cited
CCR
87465(g)
1
2
3
4
5
6
7
87465(g) Incidental Medical and Dental Care. The licensee shall immediately telephone 9-1-1 if an injury or other circumstance has resulted in an imminent threat to a resident’s health....


This requirement was not met as evidenced by:
1
2
3
4
5
6
7
The Administrator has agreed to do the following:
1. Submit a Statement of Understanding, and the steps the facility will take to avoid similar issues from happening again and to ensure compliance to the cited regulation
8
9
10
11
12
13
14
Based on the investigation, the licensee did not comply with the section cited, as staff did not seek medical attention for R1 in a timely manner, which posed an immediate health and safety risk to R1.
8
9
10
11
12
13
14
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 MillerTELEPHONE: (818) 596-4373
LICENSING EVALUATOR NAME: Yelena AvetisyanTELEPHONE: (818) 378-8120
LICENSING EVALUATOR SIGNATURE:

DATE: 03/23/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/23/2022
LIC9099 (FAS) - (06/04)
Page: 3 of 8
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
COMPLAINT CONTROL NUMBER: 31-AS-20210430081216

FACILITY NAME:OAKMONT OF SANTA CLARITAFACILITY NUMBER:
197609905
ADMINISTRATOR:GINA SALMANFACILITY TYPE:
740
ADDRESS:28650 NEWHALL RANCH ROADTELEPHONE:
(661) 295-2025
CITY:SANTA CLARITASTATE: CAZIP CODE:
91355
CAPACITY:0CENSUS: 88DATE:
03/23/2022
UNANNOUNCEDTIME BEGAN:
08:30 AM
MET WITH:Hugo Lemus and Tom Park TIME COMPLETED:
07:05 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Staff did not assist resident with eating as needed
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
An unannounced subsequent complaint visit was conducted on this day by Licensing Program Analyst (LPA) Yelena Avetisyan. Upon arrival, the LPA met with Administrator Tom Park and Health Services Director Hugo Lemus.
Regarding the allegation of: Staff did not assist resident with eating as needed it was reported that staff failed to ensure R1 was eating meals regularly while in isolation. On various days from 12/21/2021 to 3/22/2022 LPA conducted interview with various facility staff and reviewed R1's facility records on 12/16/2021.

Records reviewed revealed the following: R1’s care plan indicated R1 “Required meal time reminders”. Interviews conducted with staff revealed that prior to the COVID outbreak at the facility R1 would go to the dinning room on a scooter for meals. Staff interviews also revealed that R1 had a good appetite and would eat most meals prior to testing positive for COVID. For Approximately 2 to 5 days before hospitalization R1 began to refuse meals, staff attempted to convince R1 to eat but were unsuccessful, because R1 was refusing to eat Staff provided ensure which R1 would drink in small amounts. Some of the Ensure would dribble out from R1's mouth. Information obtained during the course of the investigation revealed that provided assistance with eating therefore the allegation is Unsubstantiated.
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Eva MillerTELEPHONE: (818) 596-4373
LICENSING EVALUATOR NAME: Yelena AvetisyanTELEPHONE: (818) 378-8120
LICENSING EVALUATOR SIGNATURE:

DATE: 03/23/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/23/2022
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 8
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 CLARITAFACILITY NUMBER:
197609905
ADMINISTRATOR:GINA SALMANFACILITY TYPE:
740
ADDRESS:28650 NEWHALL RANCH ROADTELEPHONE:
(661) 295-2025
CITY:SANTA CLARITASTATE: CAZIP CODE:
91355
CAPACITY:0CENSUS: 88DATE:
03/23/2022
UNANNOUNCEDTIME BEGAN:
08:30 AM
MET WITH:Hugo Lemus and Tom Park TIME COMPLETED:
07:05 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Licensee did not maintain sufficient staffing
Staff did not meet resident's incontinence needs
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
An unannounced subsequent complaint visit was conducted on this day by Licensing Program Analyst (LPA) Yelena Avetisyan. Upon arrival, the LPA met with Administrator Tom Park and Health Services Director Hugo Lemus.

On 05/03/2021, An initial 10 day complaint visit was conducted by LPA W. Smith. On that day, LPA Smith conducted a tour of the facility, spoke with the administrator, reviewed and obtained copies of documents related to the complaint investigation.

On 12/7/2021 LPA Avetisyan sent an email to Mr. Lemus and Mr. Park requesting the following documents Staff Schedule for the month of December 2020, time sheets for all staff for December 2020, contact information for staff. List of all Agency staffed working for the facility for the month of December 2020, contact information for the agency used.

Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Eva MillerTELEPHONE: (818) 596-4373
LICENSING EVALUATOR NAME: Yelena AvetisyanTELEPHONE: (818) 378-8120
LICENSING EVALUATOR SIGNATURE:

DATE: 03/23/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/23/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 5 of 8
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
VISIT DATE: 03/23/2022
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
On 12/16/2021, a subsequent complaint visit was conducted by LPA Y. Avetisyan. During the visit LPA conducted interview with Mr. Lemus, and facility staff, reviewed electronic file for resident 1 (R1). Obtained copies of the requested timecards for the month of December 2020.

On 1/21/2021 LPA requested names for all agency staff who worked at the facility January 2020, contact information for staff and timecards/dates worked

On 3/18/2022 LPA received an email from Mr. Park indicating that there was only 1 agency staff who was assigned to work with COVID19 positive Residents, along with Mr. Lemus and 2 other facility staff which is inconsistent with the information obtained from various staff interviews.

During today’s visit LPA conducted interview with facility staff, obtained names of Agency staff who worked at the facility December 2020.

Regarding the allegation of: Licensee did not maintain sufficient staffing it was reported that the facility did not have sufficient staff working at the facility to meet residents’ needs.

During the course of the investigation, the LPA conducted interviews with facility staff on various days from 12/21/2021 to 3/22/2022, reviewed staff schedules and timecards from December 14, 2020 to December 22,2020. Records reviewed and interviews conducted revealed the following: When interviewed on 12/16/2021 Health Services Director Hugo Lemus acknowledged staffing shortages due to a COVID19 outbreak at the facility involving residents and staff. According to Mr.Lemus the licensee contracted with two staffing agencies to provide staff coverage. When interviewed facility staff also confirmed not having sufficient staffing due to a COVID19 outbreak. Timecards reviewed revealed that on various days the licensee did not have caregivers working in Assisted living during the afternoon/evening and NOC shift. Timecards also revealed that on various days the facility did not have any med-techs working at the facility after approximately 12:00 am to 6:00 am. LPA discussed this information with Mr. Lemus who stated that agency staff were working on the days that facility staff were not. During the course of the investigation LPA made requests for Agency staff schedules which were not provided. According to Mr. Lemus they did not keep records of agency staff schedules.

Based on the information obtained during the course of the investigation the allegation is Substantiated.

SUPERVISOR'S NAME: Eva MillerTELEPHONE: (818) 596-4373
LICENSING EVALUATOR NAME: Yelena AvetisyanTELEPHONE: (818) 378-8120
LICENSING EVALUATOR SIGNATURE:

DATE: 03/23/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/23/2022
LIC9099 (FAS) - (06/04)
Page: 6 of 8
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
VISIT DATE: 03/23/2022
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
Regarding the allegation of Staff did not meet resident's incontinence needs , it was reported that resident 1 (R1’s) was not receiving regular assistance with diaper changes/incontinence needs. Records reviewed and interviews conducted revealed the following. R1’s care plan indicated the R1 needed assistance with toileting and was “Occasionally incontinent of bladder or bowel”, however according to staff interviews R1 was extremely incontinent and had “lots of accident”. Prior to R1 testing positive for COVID19 staff reported checking on resident and changing diapers at least every 2 hours. During the 12/16/2021 visit LPA was informed by Mr. Lemus the licensee does not have a bowel and/or bladder programs designed by an appropriately skilled professional. After R1 tested positive for COVID19 care for all COVID 19 positive residents would be provided by Mr. Lemus, two other facility staff and agency staff. During the course of the investigation the LPA was unable to determine if R1 received incontinence care during the afternoon/evening and NOC shift.

Based on the information obtained during the course of the investigation the allegation is Substantiated.

Per California Code of Regulations (CCR), Title 22, Division 6, Chapter 8, the following deficiencies are cited (Refer to LIC 9099-D). Exit Interview Conducted /Appeal Rights Discussed and Copy of Report emailed.

SUPERVISOR'S NAME: Eva MillerTELEPHONE: (818) 596-4373
LICENSING EVALUATOR NAME: Yelena AvetisyanTELEPHONE: (818) 378-8120
LICENSING EVALUATOR SIGNATURE:

DATE: 03/23/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/23/2022
LIC9099 (FAS) - (06/04)
Page: 7 of 8
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: 03/23/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Deficiency Dismissed
Type A
03/28/2022
Section Cited
CCR
87411(a)
1
2
3
4
5
6
7
87411(a) Personnel Requirements – General. (a) Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs....Additional staff ...employed ...perform office work, cooking,...This requirement was not met as evidenced by:
1
2
3
4
5
6
7
Licensee/Administrator will submit a Detailed explanation why they did not keep records of Agency staff worked schedule. Licensee/Administrator will also submit a plan indicating how the facility will have sufficient staff to meet all the needs of residents in care in both Assisted Living and Memory Care.
8
9
10
11
12
13
14
Based on interviews and record review, the licensee did not comply with the above section as they did not have having sufficient staffing to meet resident needs, which posed an immediate health, safety and personal rights risk to residents in care.
8
9
10
11
12
13
14
Deficiency Dismissed
Type B
04/01/2022
Section Cited
CCR
87625(b)(4)
1
2
3
4
5
6
7
(b) In addition to Section 87611, the licensee shall be responsible for the following: (4)Ensuring that bowel and/or bladder programs are designed by an appropriately skilled professional with training and experience in care of elderly persons with bowel and/or bladder dysfunction and development of retraining programs for restoration of normal
1
2
3
4
5
6
7
Licensee/Administrator will Review Regulation 87625 submit a Statement of Understanding to CCLD and what steps will be taken to ensure they are in compliance with the cited regulation.
8
9
10
11
12
13
14
patterns of continence. This requirement was not met as evidenced by: Based on record review and interview the licensee did not comply with the cited section by not having a bowel and/or bladder programs designed by an appropriately skilled professional which poses a potential health and safety risk to residents in care.
8
9
10
11
12
13
14
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 MillerTELEPHONE: (818) 596-4373
LICENSING EVALUATOR NAME: Yelena AvetisyanTELEPHONE: (818) 378-8120
LICENSING EVALUATOR SIGNATURE:

DATE: 03/23/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/23/2022
LIC9099 (FAS) - (06/04)
Page: 8 of 8