197610183-10-26-2022-31-AS-RRAZ-CL6PAH-20221114100846

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197610183
Report Date: 10/26/2022
Date Signed: 10/26/2022 04:10:29 PM

Unsubstantiated

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
10/19/2022 and conducted by Evaluator Angela Panushkina

COMPLAINT CONTROL NUMBER: 31-AS-20221019110538

FACILITY NAME:	OAKMONT OF VALENCIA		FACILITY NUMBER:	197610183
ADMINISTRATOR:	CYNTIA DRACHENBERG		FACILITY TYPE:	740
ADDRESS:	24070 COPPER HILL DRIVE		TELEPHONE:	(661) 568-6080
CITY:	VALENCIA	STATE: CA	ZIP CODE:	91354
CAPACITY:	144	CENSUS: 102	DATE:	10/26/2022
		UNANNOUNCED	TIME BEGAN:	10:10 AM
MET WITH:	Cyntia Drachenberg, Executive Director		TIME COMPLETED:	11:00 AM

ALLEGATION(S):

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Resident sustained injuries from falls while in care

INVESTIGATION FINDINGS:

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At 10:10am, Licensing Program Analyst (LPA) Angela Panushkina made an unannounced subsequent visit to finish investigation into the allegation above. LPA met with an Executive Director and explained the reason for the visit.

LPA made the initial complaint visit on 10/22/22 and conducted interviews with Memory Care Director, five (5) out of five (5) staff, one (MedTech) and reviewed facility records. LPA also obtained copies of pertinent documents relevant to the investigation. During today’s visit, LPA interviewed Executive Director.

Regarding the allegation that Resident sustained injuries from falls while in care, it was alleged that on 10/18/22, at 1:30pm, R1 was left in a Memory Care Unit (TV room) and sustained more injuries due to fall. Review of Unusual Incident/Injury Report (incident occurred at 1:15pm) submitted by the facility on 10/18/22 indicated that R1 had an unwitnessed fall and no injuries were noted. Second (unwitnessed) incident that
Continue on LIC9099-C

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Nichelle Gillyard	TELEPHONE: (818) 596-4341
LICENSING EVALUATOR NAME: Angela Panushkina	TELEPHONE: 747-230-3364
LICENSING EVALUATOR SIGNATURE:	DATE: 10/26/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/26/2022

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-20221019110538

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: 10/26/2022

NARRATIVE

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occurred on the same day, at approximately, 3:00pm indicated that R1 was found with 3 skin tears and an immediate action was taken. Also, during the investigation, LPA was provided with an eyewitness contact information. Interview with the witness, who confirmed they were at the facility on 10/18/22 around 1:30pm, revealed that R1 did not fall. An eyewitness stated: "R1 didn't actually fall. He/she folded in half and one of the caretakers caught him/her. R1 didn't fall on the floor." Although, there was an information that R1 experienced the fall, there was insufficient evidence to collaborate the allegation that R1 sustained injuries from the fall. Furthermore, interviews with three (3) out of five (5) staff members revealed that R1 has a tendency to injure self.

Based on information obtained through interviews and document review this allegation is deemed Unsubstantiated.

Exit interview conducted and copy of report was provided to Administrator.

SUPERVISOR'S NAME: Nichelle Gillyard	TELEPHONE: (818) 596-4341
LICENSING EVALUATOR NAME: Angela Panushkina	TELEPHONE: 747-230-3364
LICENSING EVALUATOR SIGNATURE:	DATE: 10/26/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/26/2022

LIC9099 (FAS) - (06/04)

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