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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197610183
Report Date: 11/03/2021
Date Signed: 11/03/2021 12:36:04 PM



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
10/26/2021 and conducted by Evaluator Angela Panushkina
COMPLAINT CONTROL NUMBER: 31-AS-20211026133955
FACILITY NAME:OAKMONT OF VALENCIAFACILITY NUMBER:
197610183
ADMINISTRATOR:FUNDERBERG, STEPHANIEFACILITY TYPE:
740
ADDRESS:24070 COPPER HILL DRIVETELEPHONE:
(661) 568-6080
CITY:VALENCIASTATE: CAZIP CODE:
91354
CAPACITY:144CENSUS: 91DATE:
11/03/2021
UNANNOUNCEDTIME BEGAN:
09:40 AM
MET WITH:Stephanie Funderburg, AdministratorTIME COMPLETED:
12:55 PM
ALLEGATION(S):
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Resident was allowed to leave the facility without staff supervision
INVESTIGATION FINDINGS:
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At 09:40am LPA, Angela Panushkina, conducted an unannounced complaint visit to the above facility. Upon arrival, LPA was screened and asked to sign-in the visitors’ log. At approximately, 09:50am the Administrator arrived and LPA explained the reason for the visit.

LPA conducted a physical plant tour of the entire facility including the Memory Care Unit. LPA tested four (4) out of four (4) facility egress system in a Memory Unit. LPA observed the egress system to be fully operational this day.

LPA interviewed the Administrator, at approximately 10:20am, and the Administrator stated that on 10/20/21 R1 pushed the egress door and care staff responded within 30 seconds. However, another resident was found near the alarming door and was escorted back to his/her room. Meanwhile, R1 exited the side door

Continue on LIC9099-C
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Nichelle GillyardTELEPHONE: (818) 596-4341
LICENSING EVALUATOR NAME: Angela PanushkinaTELEPHONE: 747-230-3364
LICENSING EVALUATOR SIGNATURE:

DATE: 11/03/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/03/2021
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 3
Control Number 31-AS-20211026133955
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 VALENCIA
FACILITY NUMBER: 197610183
VISIT DATE: 11/03/2021
NARRATIVE
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without staff supervision and walked down the street, where he was seen and recognized by a family member of another resident and escorted back to the facility. Therefore, based on this information, the allegation is Substantiated.

An exit interview was conducted, appeal rights explained and a copy of this report given to Stephanie Funderburg, Administrator
SUPERVISOR'S NAME: Nichelle GillyardTELEPHONE: (818) 596-4341
LICENSING EVALUATOR NAME: Angela PanushkinaTELEPHONE: 747-230-3364
LICENSING EVALUATOR SIGNATURE:

DATE: 11/03/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/03/2021
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 31-AS-20211026133955
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 VALENCIA
FACILITY NUMBER: 197610183
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/03/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
11/05/2021
Section Cited
CCR
87705(k)(6)
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(k) The following initial and continuing requirements must be met for the licensee to utilize delayed egress devices on exterior doors... (6) Without violating Section 87468, Personal Rights, facility staff shall ensure the continued safety of residents...

This requirement is not met as evidenced by:
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Licensee shall provide written plan of action to show the steps they will take to prevent this issue from happening again. POC must be submitted to CCL by POC due date.
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Based on interviews and record review, the licensee did not comply with the section cited above by failing to ensure the safety of resident who wondered away from the facility, which poses an immediate health, safety and personal risk to persons 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: Angela PanushkinaTELEPHONE: 747-230-3364
LICENSING EVALUATOR SIGNATURE:

DATE: 11/03/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/03/2021
LIC9099 (FAS) - (06/04)
Page: 3 of 3