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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 03:23:23 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
10/06/2022 and conducted by Evaluator Angela Panushkina
COMPLAINT CONTROL NUMBER: 31-AS-20221006103434
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 Benson, Executive Director. TIME COMPLETED:
02:00 PM
ALLEGATION(S):
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Resident sustained an unexplained injury in care.
Resident sustained multiple falls due to lack of supervision.
Facility is not meeting resident's nighttime supervision needs.
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. LPA met with the Executive Director and explained the reason for the visit.

On 10/06/2022, the Woodland Hills South Adult and Senior Care Regional Office received a complaint regarding the allegations: "Resident sustained an unexplained injury in care." "Resident sustained multiple falls due to lack of supervision." "Facility is not meeting resident's nighttime supervision needs."

On 10/07/22 an initial visit was conducted by LPA Panushkina. On that day LPA 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 Laarni Santiago, Investigator from Community Care Licensing
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-20221006103434
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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Division’s Investigations Branch (IB). The investigation consisted of interviews with R1’s family members, facility Executive Director, Health Services Director, Memory Care Director, two (2) Resident Coordinators, two (2) Medical Technician's, Hospice Nurse, two (2) Facility Care Providers, two (2) Private companions (hired by R1's family), Housekeeping, R1's records review - included but not limited to physicians report (signed and dated on 01/11//2019 - 04/14/21 and 10/21/22), resident care notes (from 04/29/21 to 10/06/22), 1st Hospice care plan (dated as of 10/22/2022), 2nd Hospice care plan (dated as of 10/10/22) and other relevant documentation. Investigator, Santiago, also subpoenaed R1’s Medical Records on 10/13/22 and reviewed on 12/23/22.

Allegation: "Resident sustained an unexplained injury in care."

The investigation findings revealed that R1 had been living at this facility, in a Memory Care Unit, since April 2021. Interview with R1’s family revealed that R1 continued to have multiple falls from 09/12/22 that resulted in bruising and skin tear. Review of medical records confirmed that on 09/12/22, the facility initiated emergency medical services and resident was later diagnosed with a nasal tip fracture after an unwitnessed fall that staff was unable to explain. In addition, on 10/08/2022, family brought R1 for a doctor’s visit due to unexplained bruising and confirmed that R1 sustained three rib fractures. Lastly, R1 continued to have multiple falls that resulted in bruising and skin tear until R1 moved out of the facility on 10/26/2022, due to hospitalization from another fall. Based on interviews and document review, during the course of the investigation, there is sufficient evidence to conclude that the above allegation is Substantiated.

Allegation: "Resident sustained multiple falls due to lack of supervision."

Although the family brought on multiple companions for R1, they were not always available and were unsuccessful in preventing falls and reducing injuries. Facility was aware of the R1’s decline, yet interviews and records verified that there were no updated reappraisals or fall plan in place to reflect on managing the resident’s change of condition. Staff revealed inconsistent information on how often they checked on resident. Throughout the course of the resident’s decline, Executive Director advised the family that they don’t have the staffing to meet R1’s needs and suggested getting a one-on-one caregiver or placing R1 in another community more suitable for his/her needs. Although the Executive Director communicated with the family about moving R1, they admitted they were willing to let the family extend their notice, knowing the facility
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-20221006103434
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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could no longer meet R1's needs. Facility neglected to produce an appropriate fall plan and retained the resident, knowing that the facility did not have adequate care and supervision to meet R1's needs. Lastly, the Regional Office received twelve (12) unwitnessed fall incident reports form 09/12/22 to 10/26/22. Based on interviews and document review, during the course of the investigation, there is sufficient evidence to conclude that the above allegation is Substantiated.

Allegation: "Facility is not meeting resident's nighttime supervision needs."

Interview with R1's family revealed that they were initially told by the facility that R1's room had a motion detector that would alert staff of the fall, but later discovered that it was inoperable. In addition, the family was advised that the facility was going to place a bed alarm that would notify staff when R1 got up, but the facility
failed to supply that. Finally, interview with the Executive Director revealed that the family was informed that the facility did not have enough staff to supervise R1 at night and requested the family to provide R1 with one-on-one caregiver or move R1 to another home. 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).

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: 3 of 6
Control Number 31-AS-20221006103434
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
87705(c)(5)(A)
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Care of Persons with Dementia
(c) Licensees who accept and retain residents with dementia... (5) Each resident with dementia... A) When any medical assessment... ...corresponding changes shall be made...

This requirement is not met as evidenced by:
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Licensee/Administrator agreed to schedule vendorized training for all staff regarding Regulation 87705(c0(5)(A) Licensee/Administrator will submit the credentials of the trainer with the scheduled training dates by 03/31/2023 and completion of training by 03/31/2023.
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Based on the information obtained, by the Investigator, licensee did not comply with the section cited above by failing to provide an updated care plan to address R1's chronic falls, which poses/posed an immediate health and safety risk to residents in care.
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Licenee/Administrator also agreed to Submit Statement of Understanding, detailing how the facility will maintain compliance of Regulation 87705(c)(5)A) by POC date to LPA
Because this violation resulted in resident sustaining a serous bodily injury immediate civil penalty in the amount of $500 is issued.
Type A
03/31/2023
Section Cited
CCR
87705(4)
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Care of Persons with Dementia
(4) There is an adequate number of direct care staff to support each resident’s physical, social, emotional, safety and health care needs as identified in his/her current appraisal.

This requirement is not met as evidenced by:
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Licensee/Administrator agreed to conduct by-weekly meetings with all staff regarding residents changes (if any). Licensee/Administrator will complete an appraisal of needs for specific client/residents to identify individual needs and develop a service plan for meeting those needs. If the client/resident is accepted for placement the staff person responsible for
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Based on the information obtained, by the Investigator, Licensee/Administrator did not comply with the section cited above by knowing that R1 needed 1:1 staffing and did not put into current appraisal as the appraisal was never updated, which poses/posed an immediate health and safety risk to residents is care.
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admission shall jointly develop a needs and services plan with the client/resident’s authorized representative referral agency/person, physician, social worker or other appropriate consultant. Licenee will also Submit Statement of Understanding, detailing how the facility will maintain compliance of Regulation 87705(4) by POC date to LPA
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: 4 of 6
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
10/06/2022 and conducted by Evaluator Angela Panushkina
COMPLAINT CONTROL NUMBER: 31-AS-20221006103434

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:TIME COMPLETED:
02:00 PM
ALLEGATION(S):
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Facility is not meeting resident's personal hygiene needs.
INVESTIGATION FINDINGS:
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At 10:00am, Licensing Program Analyst (LPA) Angela Panushkina conducted an unannounced subsequent complaint visit to deliver the final report. LPA met with the Executive Director and explained the reason for the visit.

On 10/07/22 an initial visit was conducted by LPA Panushkina. On that day LPA conducted tour of the facility, interviewed with facility staff and obtained copies of pertinent information related to the allegation. On 02/07/23, LPA conducted a subsequent complaint visit to gather additional information pertaining to the allegation. In addition, LPA conducted a physical plant walk though and interviewed the Executive Director, Memory Care Director, Resident Care Coordinator, Activity Coordinator, MedTech, three (3) staff members, five (5) out of seven (7) residents, who were able to communicate between 12:25pm - 3:30pm.

Continue on 9099-C
Unsubstantiated
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: 5 of 6
Control Number 31-AS-20221006103434
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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Allegation: Facility is not meeting resident's personal hygiene needs.

It was alleged that R1 did not shower/shave nor had their teeth brushed due to facility being understaffed. During the subsequent visit made on 02/07/23, LPA conducted a physical inspection in a Memory Care Unit and observed twelve (12) residents in a dining and TV area wearing clean clothes, well groomed and appeared well taken care of. In addition, interviews with the Executive Director and three (3) staff members revealed that the facility provides basic services (grooming, bathing, dressing, etc.) to all residents. Moreover, LPA observation, record reviews and interviews revealed that all hygiene needs are being met and that residents are scheduled to have showers at least two (2) to three (3) times a week or as needed and the facility caregivers are on standby for those who need assistance.

Based on interviews, document reviews and LPA observation, there is not enough information to verify the allegation. Therefore, the allegation is UNSUBSTANTIATED at this time.

An exit interview was conducted, and a copy of this report was provided to the Executive Director.
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: 6 of 6