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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197609905
Report Date: 12/05/2022
Date Signed: 12/05/2022 11:03:19 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
07/21/2020 and conducted by Evaluator Patrick Shanahan
COMPLAINT CONTROL NUMBER: 31-AS-20200721103138
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: 0DATE:
12/05/2022
UNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Tom Park/ AdministratorTIME COMPLETED:
11:15 AM
ALLEGATION(S):
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9
Resident sustained injuries from multiple falls
Facility failed to seek medical attention timely
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA), Patrick Shanahan, returned to the facility to issue a civil penalty for the deficencies that were assessed on 6/15/2022. None of the findings were changed and only civil penalties assessed.

Exit interview conducted and report issued.
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Nichelle GillyardTELEPHONE: (818) 596-4341
LICENSING EVALUATOR NAME: Patrick ShanahanTELEPHONE: (747) 230-2225
LICENSING EVALUATOR SIGNATURE:

DATE: 12/05/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/05/2022
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 2
Control Number 31-AS-20200721103138
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: 12/05/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
06/15/2022
Section Cited
CCR
87465(g)
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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 including, but not limited to, an apparent life-threatening medical crisis except as specified in Sections 87469(c)(2), (c)(3), or (c)(4). This requirement is not met as evidenced by:
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Licensee/Administrator will submit a written statement notifying the Department what steps will be taken to prevent a repeat of such incidents.
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Based on IB investigation record review and interview, the licensee/administrator, facility staff failed to call 9-1-1 after the initial fall of R1 which resulted in R1's injuries, which poses an immediate health, safety, and personal rights risk to residents in care.
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Type A
06/15/2022
Section Cited
CCR
87466
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The licensee shall ensure that residents are regularly observed for changes in physical, ..functioning & ...assistance is provided ...When changes such as... physical health condition are observed, the licensee shall ensure that such changes are ...brought to the attention of the resident's physician & resident's responsible person, if any.
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Licensee/Administrator will submit a written statement notifying the Department what steps will be taken to prevent a repeat of such incidents.
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Based on IB investigation record review and interview, the licensee/administrator, facility staff failed to failed to contact the family members regarding R1's fall and injuries which poses an immediate health, safety, and personal rights risk to residents in care.
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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: Nichelle GillyardTELEPHONE: (818) 596-4341
LICENSING EVALUATOR NAME: Patrick ShanahanTELEPHONE: (747) 230-2225
LICENSING EVALUATOR SIGNATURE:

DATE: 12/05/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/05/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 2