197610183-11-16-2022-31-AS-NGID-CW9P8G-20231003110530

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197610183
Report Date: 11/15/2022
Date Signed: 11/16/2022 08:25:26 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
11/10/2022 and conducted by Evaluator Angela Panushkina

COMPLAINT CONTROL NUMBER: 31-AS-20221110143440

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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Lack of supervision resulted in resident getting assaulted by another resident while in care.

INVESTIGATION FINDINGS:

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At approximately 9:00am, Licensing Program Analyst (LPA) Angela Panushkina arrived at Oakmont of Valencia in response to the above mentioned allegation. LPA met with the Regional Operations Specialist and explained the reason for the visit.

At 10:30am, LPA conducted a physical plant tour of the facility including the Memory Care Unit. LPA interviewed the Regional Operations Specialitst, Memory Care Director, five (5) out of five (5) staff members, one (1) MedTech and five (5) residents between 10:45am to 3:00pm. LPA also obtained copies of pertinent documents relevant to the investigation.

Allegation: Lack of supervision resulted in resident getting assaulted by another resident while in care. Interviews with five (5) out of five (5) staff members revealed that R1 became more aggressive about one (1) month ago. LPA was informed that R1 wanders around the facility and tries to enter random rooms 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-20221110143440

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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and a staff member has a hard time redirecting R1. All staff members informed LPA that they were aware of R1 having the propensity to assault other residents in the facility. LPA was informed by all staff members that on 11/6/22 without any warning R1 assaulted and punch R2 in the face and no staff was around to stop the incident. Moreover, interviews with one (1) out of five (5) residents revealed that about three weeks ago R1 attempted to enter R3's room in a very aggressive way and caused R3 to be frightened of R1 ever since. In addition, interview with a MedTech revealed that R1's medical condition/mood changes around 2:30-3:00pm, and R1 becomes more combative. MedTech informed LPA that R1's medications have been changed, but the aggressive behavior towards the staff members and other residents' is still there. Interview with a Memory Care Director confirmed that R1 punched R2 in the face without provocation and caused bleeding on R2's face and 911 was called immediately. Memory Care Director informed LPA that the family took R1 to ER on 11/06/22 and once R1's medications are changed and or adjusted R1 will return to the community. Lastly, LPA reviewed one (1) incident report submitted on 10/12/22 and two (2) incident reports submitted on 10/16/22 where it was indicated that R1 assaulted a resident and two (2) staff members without any warnings.

Based on interviews and document review, during the course of the investigation the facility failed to protect residents from being assaulted by R1. Therefore, there is sufficient evidence to conclude that the above allegation is Substantiated at this time.

Pursuant to Title 22 Division 6 Chapter 8 of the CA Code of Regulations, the following deficiencies were cited (refer to LIC9099-D):

Exit interview conducted, copy of report, citations and appeal rights issued.

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-20221110143440

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 11/16/2022 Section Cited CCR 87101(b)(2)	1 2 3 4 5 6 7	Basic Services: (b)(2) "Basic Services," as defined in Health and Safety Code section 1569.312, means those services required to be provided by the facility in order to obtain and maintain a license and in such combinations as may meet the needs... 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 11/18/2022 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 licensee failed to protect R2 from being assaulted by R1 which poses an immediate health, safety and personal risk to persons in care.	8 9 10 11 12 13 14
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

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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