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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197610183
Report Date: 09/14/2022
Date Signed: 09/14/2022 06:28:53 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
08/05/2022 and conducted by Evaluator Angela Panushkina
COMPLAINT CONTROL NUMBER: 31-AS-20220805133307
FACILITY NAME:OAKMONT OF VALENCIAFACILITY NUMBER:
197610183
ADMINISTRATOR:CYNTIA DRACHENBERGFACILITY TYPE:
740
ADDRESS:24070 COPPER HILL DRIVETELEPHONE:
(661) 568-6080
CITY:VALENCIASTATE: CAZIP CODE:
91354
CAPACITY:144CENSUS: 103DATE:
09/14/2022
UNANNOUNCEDTIME BEGAN:
12:00 PM
MET WITH:Cynthiya Drachenberg, Executive DirectorTIME COMPLETED:
05:00 PM
ALLEGATION(S):
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Staff did not inform responsible party of an unusual incident
Staff did not prevent resident from wandering away from facility
INVESTIGATION FINDINGS:
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At 12:00pm 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. LPA met with the Executive Director, Cyntia Drachenberg and explained the reason for the visit.

In conjunction with a Complaint visit made on 09/01/2022, LPA conducted a physical plant tour of the entire facility including the Memory Care Unit. During that time LPA tested five (5) out of five (5) facility egress system in a Memory Units. LPA observed the egress system to be properly working and fully operational.

During the initial 10-day visit, made by LPA Avetisyan, on 08/10/22 interview with an Executive Director revealed that on 08/04/2022, at approximately, 4:05pm R1 eloped from the Memory Care Unit (Traditions 2) and was found by two staff members minutes later, in the same area as community, standing by a parked car. R1 was returned safely and the assessment showed no injuries. Executive Director also confirmed that due to 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: 09/14/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/14/2022
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 5
Control Number 31-AS-20220805133307
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: 09/14/2022
NARRATIVE
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miscommunication among the staff members, the family was not notified regarding this incident until 08/05/2022. Although, R1's family was verbally informed about the incident, no written report was send to the responsible party, timely. Moreover, on 08/26/22, the Department received another incident regarding R1's elopement which was, again, undetermined how R1 got out from the community. Therefore, based on this information, both allegations: Staff did not inform responsible party of an unusual incident and Staff did not prevent resident from wandering away from facility are Substantiated.

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

DATE: 09/14/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/14/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 31-AS-20220805133307
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: 09/14/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
09/16/2022
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. All staff trainig must be complete by POC date and copies of training materials along with sign-in sheet must be emailed to LPA
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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: 09/14/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/14/2022
LIC9099 (FAS) - (06/04)
Page: 3 of 5
Control Number 31-AS-20220805133307
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: 09/14/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/21/2022
Section Cited
CCR
87211(a)(1)(D)
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87211(a)(1) Reporting Requirements
(a) Each licensee shall furnish to the licensing agency such reports... (1) A written report shall be submitted to the licensing agency and to the person... ... any of the events specified in (D)...

This requirement is not met as evidenced by:
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Licensee shall ensure a written report is submitted to the person responsible for the resident within seven (7) days of the occurrence of any of the events. Licensee shall provide in-service training with all staff members andCopy of the training materials, along with the a sign-in sheet shall be submitted to LPA by POC date.
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Based on interviews and record reviews, conducted by LPA during the visit made on 09/01/22, the licensee did not comply with the section cited above by failing to notify residents responsible party (in writing) about the incident within seven (7) days of the occurence, which poses a potential health and safety 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: 09/14/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/14/2022
LIC9099 (FAS) - (06/04)
Page: 5 of 5