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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197610183
Report Date: 03/29/2023
Date Signed: 03/29/2023 03:35:31 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
11/10/2022 and conducted by Evaluator Angela Panushkina
COMPLAINT CONTROL NUMBER: 31-AS-20221110135757
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: 97DATE:
03/29/2023
UNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Myla Belson, Executive Director TIME COMPLETED:
02:00 PM
ALLEGATION(S):
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Resident died due to staff administering the wrong medication
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Angela Panushkina conducted an unannounced subsequent visit to this facility to deliver the final report. LPA met with Executive Director and explained the reason for the visit.

On 11/10/2022, the Woodland Hills South Adult and Senior Care Regional Office received a complaint regarding the allegation, “Resident died due to staff administering the wrong medication.” The complaint was referred to Community Care Licensing Division’s Investigations Branch. The complaint was assigned to investigator Christine Ferris.

On 11/14/22 LPA Panushkina initiated the complaint. LPA conducted tour of the facility and obtained copies of pertinent information which include but not limited to physician’s report 09/24/2019, progress notes, Medications Administration Record (MAR) for October 2022. Medications Management -General Policy related to the complaint.
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: 03/29/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/29/2023
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 6
Control Number 31-AS-20221110135757
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: 03/29/2023
NARRATIVE
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No update resident appraisal observed. LPA conducted interviews with four (4) out of four (4) staff on 11/07/2022, and Neptune Society staff, 11/08/2022.

Investigator Ferris, conducted interviews with, witnesses (on 11/30/22), Primary Care Physician (on 12/19/22), nine (9) out of nine (9) staff members (on 11/30/22, 12/27/22. 12/28/22 and 12/29/22), Los Angeles County Department of Medical Examiner-Coroner-Investigator (on 01/26/23), and subpoenaed Los Angeles County Fire Department Response Repot and 911 Audio (on 12/15/22) and reviewed on 12/20/22.

Allegation: Resident died due to staff administering the wrong medication

The investigation findings revealed that R1 had been living at this facility since September 28, 2019. Although, R1 was able to independently ambulate throughout the facility, due to the use of full-time oxygen, R1 had a wheelchair as a backup (in case of fall or weakness). In addition, findings revealed that R1 was able to manage his/her own medications and due to R1’s changes in medical condition, R1’s responsible party requested the facility to start managing/storing R1’s medications as of October 1st, 2022. During the Case Management Visit, conducted by LPA Panushkina on 11/07/22 at 12:05pm, LPA requested R1’s Centrally Stored Medications and Destruction Record (SCMDR) and observed no document was available. When LPA asked S3 why R1’s SCMDR record was left blank, S3 was unable to give an explanation and informed LPA that he/she just recently (as of October 2022) got hired. LPA also observed R1’s Appraisal Needs and Services Plan and or resident reappraisal, last dated on 06/30/2021, was not updated. During the course of investigation, LPA was also informed by S6 that although, S1 completed all required (by Oakmont) medication training, in September 2022, S1 expressed concerns numerous times to the staff and management about not being confident to independently administer medications to the residents and was scheduled to work without being provided an additional training/re-training. On 11/06/2022, S1 failed to ensure the medications were correctly dispensed and administered five (5) incorrect medications to resident (R1), which were prescribed to another resident (R2). Moreover, the facility failed to obtain timely medical attention for R1. Upon discovery that R1 was administered five (5) incorrect medications, staff was allegedly instructed to frequently check on R1 and obtain his/her "vitals", (i.e., R1’s blood pressure and oxygen saturation levels). First, no documentation was produced to show R1 was checked on at any time and no documentation was produced to show R1’s "vitals" were checked, upon Investigator Ferris’s request (on 11/30/22 and on 01/11/23). Continue on LIC9099-C
SUPERVISOR'S NAME: Nichelle GillyardTELEPHONE: (818) 596-4341
LICENSING EVALUATOR NAME: Angela PanushkinaTELEPHONE: 747-230-3364
LICENSING EVALUATOR SIGNATURE:

DATE: 03/29/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/29/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 6
Control Number 31-AS-20221110135757
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: 03/29/2023
NARRATIVE
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Second, S3 provided names of staff, to Investigator Ferris, whom he/she instructed to check on R1. Those staff were interviewed by the Investigator and denied being instructed to check on R1, denied checking on R1, and denied knowledge of the incident. There was no documentation or statements made to show any measures were taken to decrease the potential for a negative outcome from the medication error. Finally, neither emergency medical services (911), R1's Primary Care Physician, Poison Control, nor R1's family were contacted immediately after discovering R1 was given five (5) incorrect medications and no medical attention or intervention of any kind was obtained for R1 prior to death. In addition, LPA reviewed the facility’s Medication Management-General Policy on 11/17/2022. According to the “Policy #7: The medication error must be investigated by the Health Services Director (HSD) or designee. The HSD will identify the appropriate follow-up, including the notification of the responsible party and healthcare practitioner.”

Based on the information gathered, there is sufficient evidence to conclude that the above allegation is Substantiated.

A $500 immediate civil penalty is assessed today for a violation resulting R1's death. The Licensee/Executive Director were informed that additional civil penalties might be assessed based on Health and Safety Code 1569.49(e) or (f).

Exit interview conducted.

Civil penalties assessed and appeal rights explained.

Report reviewed, signed, and delivered.

SUPERVISOR'S NAME: Nichelle GillyardTELEPHONE: (818) 596-4341
LICENSING EVALUATOR NAME: Angela PanushkinaTELEPHONE: 747-230-3364
LICENSING EVALUATOR SIGNATURE:

DATE: 03/29/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/29/2023
LIC9099 (FAS) - (06/04)
Page: 4 of 6
Control Number 31-AS-20221110135757
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: 03/29/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
03/31/2023
Section Cited
CCR
87466
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87466 Observation of the Resident. The licensee shall ensure that residents are regularly observed for changes in physical, mental, emotional and social functioning and that appropriate assistance is provided when such observation reveals unmet needs.

This requirement was not met as evidenced by:
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The Licensee has agreed to do the following:
1. Develop and Submit facility protocol, which details how care staff are instructed to identify and document any changes in resident condition and what follow up actions will be taken and by whom Submit to CCL by POC date
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Based on the investigation, the licensee did not comply with the section cited above by not having a staff regularly check on or document any changes as agreed upon, which poses an immediate health and safety risk to residents in care.
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2. Schedule an in-service training with care staff ensuring that staff are trained on the facility protocol as it pertains to the observation of the resident. Submit the sign-in sheet(s) to CCL by POC date
Type A
03/31/2023
Section Cited
CCR
87465(g)
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87465(g) Incidental Medical and Dental Care. The licensee shall immediately telephone 9-1-1 if an injury or other circumstance has resulted in an imminent threat to a resident’s health....


This requirement was not met as evidenced by:
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The Administrator has agreed to do the following:
1. Submit a Statement of Understanding, and the steps the facility will take to avoid similar issues from happening again and to ensure compliance to the cited regulation
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Based on the investigation, the licensee did not comply with the section cited above, as staff did not seek medical attention for R1 in a timely manner, which poses/posed an immediate health and safety risk to residents 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: 03/29/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/29/2023
LIC9099 (FAS) - (06/04)
Page: 3 of 6
Control Number 31-AS-20221110135757
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: 03/29/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
03/31/2023
Section Cited
CCR
87462(a)
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87463 Reappraisals
(a) The pre-admission appraisal shall be updated, in writing as frequently as necessary to note significant changes and to keep the appraisal accurate.
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The Licensee agreed to develop a plan to address reappraisals of residents as frequently as necessary and provide in-service training to all staff regarding the Section 87463. Proof of training should be submitted to CCLD by POC date.
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Based on review of documentation during investigation, the licensee did not comply with the section cited above by not completing a resident appraisal due to changes in R1’s medical condition that required the assistance with medications management, which poses/posed a potential health and safety risk to residents 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: 03/29/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/29/2023
LIC9099 (FAS) - (06/04)
Page: 6 of 6
Control Number 31-AS-20221110135757
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: 03/29/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
03/31/2023
Section Cited
CCR
87411(d)(4)
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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... (4) Knowledge required to safely assist with prescribed medications...

This requirement was not met as evidence by:
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Licensee agreed that all personnel (current and or future) will receive the required training. A verification of staff training will be submitted to CCLD by POC date.
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Based on the investigation, the licensee did not comply with the section cited above, for Staff #1 (S1), which poses/posed an immediate health and safety risk to residents in care.
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Type A
03/31/2023
Section Cited
CCR
87405(b)
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87405 Administrator - Qualifications and Duties
(b) The administrator of a facility or facilities shall have the responsibility and authority to carry out the policies of the licensee.
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Licensee agreed that the facility Administrator/Executive Director, designee and all staff handling and/or administrering medications will be trained on the Facility's updated Medication Policy/Protocol. Proof of training will be submitted to CCLD by POC date.
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Based on the investigation, the Administrator/Executive Director did not comply with the section cited above, failing to follow and carry out medication policy, which poses/posed an immediate health and safety risk to residents 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: 03/29/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/29/2023
LIC9099 (FAS) - (06/04)
Page: 5 of 6