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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197610183
Report Date: 04/07/2023
Date Signed: 04/07/2023 12:19:53 PM


Document Has Been Signed on 04/07/2023 12:19 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		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 VALENCIAFACILITY NUMBER:
197610183
ADMINISTRATOR:MYLA BELSONFACILITY TYPE:
740
ADDRESS:24070 COPPER HILL DRIVETELEPHONE:
(661) 568-6080
CITY:VALENCIASTATE: CAZIP CODE:
91354
CAPACITY:144CENSUS: 97DATE:
04/07/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Myla Belson TIME COMPLETED:
12:30 PM
NARRATIVE
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Licensing Program Analyst (LPA) Tuesday Cabiness conducted a case management visit in regards to an SIR (Special Incident Report) that was submitted pertaining to resident #1 (R1) who was administered wrong medication. LPA met with Executive Director Myla Belson, who was informed the reason of the visit, and who reported to LPA, that staff # 1 (S1) accidentally administered the wrong medication to R1 because there was another resident with the same first name but different last name. S1 immediately contacted the Health Services Director, ED, and Memory Care Director. Family was also notified the same day; who was visiting R1 at the facility. R1 was sent to the hospital for evaluation, and was returned to the community, with no documentation of any medical or adverse action of the wrong medication.

The ED reported the incident to Licensing with a SIR. During today's visit. ED reported that the facility and corporate implemented additional medication training, that involves licensed registered nurses that will be conducting training on April 11 and 13, 2023. Also, ED reported that additional medication training was conducted with the Regional Health Services Specialist, who is a licensed LVN (Licensed Vocational Nurse). There responsibilities is to oversee and provide additional support and resources to facility and staff. In addition, medication procedures were changed, to resident's identification are now labeled by last name and first initial,room number, and a picture of the resident.

ED has recently hired a newly Wellness Nurse, that is currently in training, that would be available for additional medication and facility support. ED will continue ensure medication technicians receive adequate and complete training, that involves shadowing by Health Services Director, Wellness Nurse, or Resident Care Coordinator. ED will also continue to follow the training plan that was submitted previously for the plan of correction (POC).
SUPERVISOR'S NAME: Cassandra HarrisTELEPHONE: (818) 596-4342
LICENSING EVALUATOR NAME: Tuesday CabinessTELEPHONE: (818) 299-4975
LICENSING EVALUATOR SIGNATURE:
DATE: 04/07/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/07/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 04/07/2023
NARRATIVE
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ED was made aware that during today's visit a citation and repeat civil penalty will be issued due to the recent incident involving medication error.

Exit interview, appeal rights, citation and civil penalty issued to ED and copy of the report.
SUPERVISOR'S NAME: Cassandra HarrisTELEPHONE: (818) 596-4342
LICENSING EVALUATOR NAME: Tuesday CabinessTELEPHONE: (818) 299-4975
LICENSING EVALUATOR SIGNATURE:

DATE: 04/07/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/07/2023
LIC809 (FAS) - (06/04)
Page: 2 of 3
Document Has Been Signed on 04/07/2023 12:19 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 04/07/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Request Denied
Type A
04/10/2023
Section Cited

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87411 Personnel Requirements-General; (d) All personnel shall be given on the job training... This training and/or related experience shall provide knowledge of and skill in the following...This requirement was not met as evidence by:
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ED reported to LPA that a consulting group has been hired to provide additonal medication training to staff and the facility. ED will submit the subjects of the training and staff signatures of all who attended.
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(4) Knowledge required to safely assist with prescribed medications...
Staff #1 administered the wrong medication to resident #1. This poses as an immediate health and safety risk to residents in care.
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LPA is aware during the visit, the consulting group is scheduled for 04/11 & 04/13, 2023. ED must submit documentation of training on 04/14/2023.

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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: Cassandra HarrisTELEPHONE: (818) 596-4342
LICENSING EVALUATOR NAME: Tuesday CabinessTELEPHONE: (818) 299-4975
LICENSING EVALUATOR SIGNATURE:
DATE: 04/07/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/07/2023
LIC809 (FAS) - (06/04)
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