197610183-11-16-2022-31-AS-MVAO-CM4SCU-20221214124607

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197610183
Report Date: 11/15/2022
Date Signed: 11/16/2022 08:01:54 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
06/28/2022 and conducted by Evaluator Angela Panushkina

COMPLAINT CONTROL NUMBER: 31-AS-20220628085847

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: 95	DATE:	11/15/2022
		UNANNOUNCED	TIME BEGAN:	09:00 AM
MET WITH:	Julius Osorio, Regional Operations Specialist.		TIME COMPLETED:	05:30 PM

ALLEGATION(S):

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Resident sustained severe fracture while in care

INVESTIGATION FINDINGS:

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An unannounced subsequent complaint visit was conducted on this day by licensing program analyst (LPA) Angela Panushkina to issue the findings of the above listed allegation.

On 06/28/22, the Woodland Hills South Adult and Senior Care Regional Office received a complaint regarding the allegation: Resident sustained severe fracture while in care.

On 06/29/22 an initial visit was conducted by LPA W. Smith. On that day LPA Smith conducted tour of the facility, interviewed with facility staff and obtained copies of pertinent information related to the allegation.

This complaint investigation was conducted by Dennis Sang, Investigator from Community Care Licensing Division’s Investigations Branch (IB). The investigation consisted of interviews with R1’s family member, facility staff, facility Administrator, facility former residents and R1’s Medical Records.
Continue on LIC9099-C

Substantiated

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: 11/15/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/15/2022

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-20220628085847

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: 11/15/2022

NARRATIVE

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The investigation findings revealed that R1 had been living at this facility, in a Memory Care Unit, for approximately six (6) months and required an assistance with showers. Interview with R1’s family revealed that prior to the fall, which occurred on 05/31/22, R1 was able to ambulate without a walker and or wheelchair. Interviews with six (6) out of six (6) staff members revealed that on a day of an incident S1 was assigned to watch R1 and other residents in a movie theater. Interviews also revealed that an assigned Staff #1 (S1) took a break before they were relieved by another staff member and between five (5) to eight (8) Memory Care Unit residents were left in the movie theater unsupervised which led R1 to fall and sustain serious bodily injury. Moreover, during the interviews conducted by the Investigator, (S1) admitted leaving for a break before another staff member could replace them and take over the supervising duties. Lastly, review of R1’s Medical Records revealed that R1 was admitted to ER on 05/31/22 and was diagnosed with Right Femur Intertrochanteric FX (fractured/broken hip) that resulted in a surgery.

Based on interviews and document review, during the course of the investigation, there is sufficient evidence to conclude that the above allegation is Substantiated.

A $500 immediate civil penalty is assessed today for a violation resulting in injury to R1. The licensee/administrator was informed that additional civil penalties might be assessed based on Health and Safety Code 1569.49(e) or (f), or 1548(e) or (f), 1568.0822(e) or (f).

Exit interview conducted.

Civil penalties assessed and appeal rights explained.

Report reviewed, signed and delivered.

SUPERVISOR'S NAME: Nichelle Gillyard	TELEPHONE: (818) 596-4341
LICENSING EVALUATOR NAME: Angela Panushkina	TELEPHONE: 747-230-3364
LICENSING EVALUATOR SIGNATURE:	DATE: 11/15/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/15/2022

LIC9099 (FAS) - (06/04)

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Control Number 31-AS-20220628085847

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: 11/15/2022

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 11/17/2022 Section Cited CCR 87101(c)(3)(F)	1 2 3 4 5 6 7	Basic Services: (3) "Care and Supervision" means those activities which if provided shall require the facility… It involves assistance as needed with activities of daily living… (F) Supervision of resident schedules and activities; This requirement was not met as evidenced by:	1 2 3 4 5 6 7	Licensee/Administrator will schedule vendorized training for all staff regarding Regulation 87101... Licensee/Administrator will submit the credentials of the trainer with the scheduled training dates by 11/17/2022 and completion of training by 12/01/2022.
	8 9 10 11 12 13 14	Based on information obtained during the course of the investigation S1 did not comply with the cited section by neglecting and leaving demetia residents unsupervised which led R1 to fall and sustain severe hip fracture that resulted in surgery.	8 9 10 11 12 13 14	Licenee/Administrator will also Submit Statement of Understanding, detailing how the facility will maintain compliance of Regulation 87101... Because this violation resulted in resident sustaining a serous bodily injury immediate civil penalty in the amount of $500 is issued.
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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 Gillyard	TELEPHONE: (818) 596-4341
LICENSING EVALUATOR NAME: Angela Panushkina	TELEPHONE: 747-230-3364
LICENSING EVALUATOR SIGNATURE:	DATE: 11/15/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/15/2022

LIC9099 (FAS) - (06/04)

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