197610183-3-20-2024-31-AS-MVAO-CUJTSZ-20230809145957

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197610183
Report Date: 06/15/2023
Date Signed: 03/20/2024 05:15:26 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
06/08/2023 and conducted by Evaluator Melissa Ruiz

PUBLIC

COMPLAINT CONTROL NUMBER: 31-AS-20230608081726

FACILITY NAME:	OAKMONT OF VALENCIA		FACILITY NUMBER:	197610183
ADMINISTRATOR:	MYLA BELSON		FACILITY TYPE:	740
ADDRESS:	24070 COPPER HILL DRIVE		TELEPHONE:	(661) 568-6080
CITY:	VALENCIA	STATE: CA	ZIP CODE:	91354
CAPACITY:	144	CENSUS: 97	DATE:	06/15/2023
		UNANNOUNCED	TIME BEGAN:	10:00 AM
MET WITH:	Myla Belson - Executive Director		TIME COMPLETED:	02:15 PM

ALLEGATION(S):

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Resident choked another resident in care.

INVESTIGATION FINDINGS:

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This is an Amendment to the original report, issued on 06/15/23, to correct the section number indicated in the deficiency box and update the typographical error made under the section number 87411(a)(2).

On 6/15/2023, Licensing Program Analyst (LPA) Melissa Ruiz arrived at the facility to conduct an initial complaint investigation. Upon arrival, LPA was greeted by staff and the Executive Director, Myla Belson. An entrance interview was conducted, and the purpose of the visit was explained.

Allegation: Resident choked another resident in care.

It is alleged that on 6/6/23, resident #1 (R1) was sent to the emergency department at the hospital, because R1 was choked by another resident (R2). To investigate this allegation, LPA conducted an interview with the Executive Director at 10:30 a.m. and the Executive Director confirmed that on 6/6/23, there was an
Continue on LIC9099-C

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Nichelle Gillyard	TELEPHONE: (818) 596-4341
LICENSING EVALUATOR NAME: Angela Panushkina	TELEPHONE: (818) 401-7980
LICENSING EVALUATOR SIGNATURE:	DATE: 03/20/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/20/2024

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-20230608081726

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: 06/15/2023

NARRATIVE

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unwitnessed altercation between two residents. The incident was unwitnessed, however R1 reported to the Med-Tech (S1) on shift that they had neck pain due to the incident that had occurred. Afterwards, the Med-Tech called emergency services, and R1 was taken to the local hospital for evaluation. Executive Director stated that they believe this incident happened in the hallway, since both resident rooms were next to each other.

Executive Director stated that since the incident, R1 has been moved to another unit in memory care, in service training for managing difficult behaviors was completed for staff, and R2 had a physician’s appointment on 6/7/23 where their medications were adjusted, and an updated Individualized Service Plan (ISP) was completed today, on 6/15/2023. At 1:30 p.m. an interview was conducted with R1, and R1 confirmed the incident occured.

LPA conducted record review from 11:00 – 12:00 p.m. and the following was reviewed:

• LIC500
• Resident Roster
• Physician’s Report for R1 and R2
• ISP’s for R2 dated 1/26/23, 2/15/23, and 6/15/23
• Physician’s prescription for updated medication for R2
• Med-Tech notes regarding incident on 6/6/23
• In-Service sign in sheet – Managing Difficult Behavior done 6/7/23
• Incident Reports 6/6/23, 2/10/23
'
An incident report was submitted to CCL by the ED 6/6/23 and a SOC341 explaining the incident between both residents.LPA observed R2’s ISP to have been updated on 2/15/23, after an incident occurred on 2/10/23, where R2 was found in R1’s bedroom and R1 told staff that R2 had tried to rape them. Due to interviews conducted and records reviewed, it is determined that this was not an isolated incident, and the allegation mentioned above is substantiated.

Deficiencies issued per CA Code of Regulations, Title 22. Report signed and delivered. Appeal rights issued. Deficiency cleared as of today's visit.

SUPERVISOR'S NAME: Nichelle Gillyard	TELEPHONE: (818) 596-4341
LICENSING EVALUATOR NAME: Angela Panushkina	TELEPHONE: (818) 401-7980
LICENSING EVALUATOR SIGNATURE:	DATE: 03/20/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/20/2024

LIC9099 (FAS) - (06/04)

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Control Number 31-AS-20230608081726

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: 06/15/2023

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Request Denied Type A 06/17/2023 Section Cited CCR 87468.1(a)(2)	1 2 3 4 5 6 7	87468.1 Personal Rights of Residents in All Facilities (a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (2)To be accorded safe, healthful and comfortable accommodations, furnishings and equipment. This requirement is not met as evidenced by:	1 2 3 4 5 6 7	Executive Director stated that since the incident, R1 has been moved to another unit in memory care, in service training for managing difficult behaviors was completed for staff, and R2 had a physician’s appointment on 6/7/23 where their medications were adjusted, and an updated Individualized Service Plan (ISP) was completed today, on 6/15/2023. Deficiency cleared as of today's visit.
	8 9 10 11 12 13 14	Based on records reviewed and interviews, it was determined that R2 choked or physically grabbed R1 by the neck. Additionally, there was a previous incident report that stated on 2/10/23, R2 was caught in R1's bedroom. The behavior issues exhibited by R2 towards R1 posess an immediate health and safety risk or personal rights risk to residents in care.	8 9 10 11 12 13 14
ILS	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: (818) 401-7980
LICENSING EVALUATOR SIGNATURE:	DATE: 03/20/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/20/2024

LIC9099 (FAS) - (06/04)

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