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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197610183
Report Date: 08/10/2022
Date Signed: 11/18/2022 08:55:34 AM

Unsubstantiated


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
10/18/2021 and conducted by Evaluator Yelena Avetisyan
PUBLIC
COMPLAINT CONTROL NUMBER: 31-AS-20211018141211
FACILITY NAME:OAKMONT OF VALENCIAFACILITY NUMBER:
197610183
ADMINISTRATOR:FUNDERBERG, STEPHANIEFACILITY TYPE:
740
ADDRESS:24070 COPPER HILL DRIVETELEPHONE:
(661) 568-6080
CITY:VALENCIASTATE: CAZIP CODE:
91354
CAPACITY:144CENSUS: 99DATE:
08/10/2022
UNANNOUNCEDTIME BEGAN:
10:15 AM
MET WITH:Cynthia DrachenbergTIME COMPLETED:
02:00 PM
ALLEGATION(S):
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Questionable Death
INVESTIGATION FINDINGS:
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An unannounced initial 10 day complaint visitr was condcuted on this dat by licensing progra analys (LPA) Yelena Avetisyan. Upon arrival LPA met with Executive Director, Cyntia Drachenberg and explained the reason for the visit.

On 10/18/2021, the Woodland Hills South Adult and Senior Care Regional Office received a complaint regarding an allegation of a questionable death. It was alleged that facility Resident #1 (R1) died due to medical conditions developing from the severe facial injuries sustained at the facility.

On 10/19/2021 an initial 10-day visit was conducted by LPA A. Panushkina to initiate the investigation. On that day LPA Panushkina conducted tour of the facility reviewed records and obtained copies of pertinent records.
On 4/13/2022 Licensing Program Analyst (LPA) Yelena Avetisyan emailed subpoena for records to Tri Valley Hospice Care, Inc. Records were received on 4/22/2022. Hospice records reviewed revealed that after 10/9/2021 hospitalization R1 was discharged to Option One Congregate Living Facility.
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Eva MillerTELEPHONE: (818) 596-4373
LICENSING EVALUATOR NAME: Yelena AvetisyanTELEPHONE: (818) 378-8120
LICENSING EVALUATOR SIGNATURE:

DATE: 08/10/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/10/2022
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-20211018141211
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: 08/10/2022
NARRATIVE
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On 5/11/2022 LPA Avetisyan requested copy of R1’s death Certificate from Option One Congregate living and Tri Valley Hospice. Copies of the Death certificate were received on 5/12/2022 and 5/11/2022. Upon review, both copies of the death certificate documented R1’s cause of death to be Advanced Parkinson’s without any other contributing diagnosis.

Based on the information obtained, there is insufficient evidence to support the allegation, therefore the allegation of Question death is deemed Unsubstantiated at this time.



Exit interview conducted, copy of report and appeal rights issued.
SUPERVISOR'S NAME: Eva MillerTELEPHONE: (818) 596-4373
LICENSING EVALUATOR NAME: Yelena AvetisyanTELEPHONE: (818) 378-8120
LICENSING EVALUATOR SIGNATURE:

DATE: 08/10/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/10/2022
LIC9099 (FAS) - (06/04)
Page: 6 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
10/18/2021 and conducted by Evaluator Yelena Avetisyan
COMPLAINT CONTROL NUMBER: 31-AS-20211018141211

FACILITY NAME:OAKMONT OF VALENCIAFACILITY NUMBER:
197610183
ADMINISTRATOR:FUNDERBERG, STEPHANIEFACILITY TYPE:
740
ADDRESS:24070 COPPER HILL DRIVETELEPHONE:
(661) 568-6080
CITY:VALENCIASTATE: CAZIP CODE:
91354
CAPACITY:144CENSUS: 99DATE:
08/10/2022
UNANNOUNCEDTIME BEGAN:
10:15 AM
MET WITH:Cynthia DrachenbergTIME COMPLETED:
02:00 PM
ALLEGATION(S):
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Resident 1 (R1) sustained an unexplained injury for which the staff failed to obtain timely medical care
Due to staff neglect Resident 1 (R1) sustained severe facial injuries.
INVESTIGATION FINDINGS:
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An unannounced subsequent complaint visit was conducted on this day by Licensing Program Analyst (LPA) Yelena Avetisyan to deliver the findings regarding the allegations, ‘Resident 1 (R1) sustained an unexplained injury while in care and, Facility staff failed to seek timely medical attention for resident.

On 10-18-2021, a complaint was received by the Woodland Hills South Adult and Senior Care Regional Office. The complaint was referred to and accepted by Community Care Licensing Division’s, Investigation Branch. The investigation was assigned to Investigator, Robert Kujuwa

On 10/19/2021 an initial 10-day visit was conducted by LPA A. Panushkina to initiate the investigation. On that day LPA Panushkina conducted tour of the facility reviewed records and obtained copies of pertinent records.

Medical records were requested by the office of Investigations. The records were received and reviewed on 11-29-2021 by Investigator Kujuwa. Additionally, on various days 2/14/2022, 3/9/2022 and 3/11/2022 Investigator Kujuwa conducted interviews with, facility staff and on 3/18/2022 conducted interview with the complainant.
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Eva MillerTELEPHONE: (818) 596-4373
LICENSING EVALUATOR NAME: Yelena AvetisyanTELEPHONE: (818) 378-8120
LICENSING EVALUATOR SIGNATURE:

DATE: 08/10/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/10/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 2 of 6
Control Number 31-AS-20211018141211
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: 08/10/2022
NARRATIVE
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On 4/13/2022 Licensing Program Analyst (LPA) Yelena Avetisyan emailed subpoena for records to Tri Valley Hospice Care, Inc. Records were received on 4/22/2022.

On 5/11/2022 a subsequent complaint visit was conducted by Licensing Program Analyst (LPA) Yelena Avetisyan. On that day LPA Avetisyan conducted re-review of R1’s facility records and interviewed staff who were working at the facility when the 9/11/2021 and 10/9/2021 injuries occurred.

Records reviewed and interviews conducted revealed the following:

In regard to the allegation of: Resident 1 (R1) sustained an unexplained injury for which the staff failed to obtain timely medical care: It was reported that on 9/11/2021 R1 was taken to Henry Mayo Newhall emergency room with a dislocated left shoulder and staff were not aware how R1 sustained the injury. On 10/19/2021 LPA Panushkina communicated with R1’s family who reported that upon their return from the emergency room staff reported to them that R1 started feeling pain after dinner, and hospice was called the next morning because of the pain worsening. While conducting review of facility records LPA Avetisyan observed the following documented on the licensees Resident Care Notes: 9/10/2021 at 22:15 pm staff requested assistance from the med-tech because R1 was “grimacing when touching left shoulder”. Upon med-tech documented slight swelling on L side. Staff noted “informed the health director, also to contact hospice and monitor shoulder and pain” On 9/11/2021 at 23:50 am Med-tech documented R1 “in a lot of pain L shoulder hurting to slightest touch. Called Hospice will send a nurse in the morning” per staff notes the hospice instructed to administer morphine as PRN. However, the hospice communication log documented the hospice agency receiving a call to see R1 due to severe pain and swelling to the left shoulder. Caregiver reported R1 “is crying, grimacing, pulling back” Hospice communication log also documents caregiver reported giving R1 2 doses of morphine for severe pain. The call was documented on the communication log on 9/11/2021 at 09:30 am. Hospice staff arrived at the facility approximately 9:15 am on 9/11/2021 and transported to the hospital by Power of Attorney at approximately 10:00 am. However, hospital records document resident being admitted to the Emergency room 14:38 pm. Additional information obtained during the course of the investigation revealed that facility and hospice records documented R1 being a fall risk however licensee did not have a fall risk plan in place. Staff are asked to call Hospice agency first for any incident that occurs with residents regardless if the reason for the call is related to the terminal diagnosis. The licensee/administrator failed to follow reporting requirements related to this incident.

SUPERVISOR'S NAME: Eva MillerTELEPHONE: (818) 596-4373
LICENSING EVALUATOR NAME: Yelena AvetisyanTELEPHONE: (818) 378-8120
LICENSING EVALUATOR SIGNATURE:

DATE: 08/10/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/10/2022
LIC9099 (FAS) - (06/04)
Page: 3 of 6
Control Number 31-AS-20211018141211
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: 08/10/2022
NARRATIVE
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In regard to the allegation of: Due to staff neglect Resident 1 (R1) sustained severe facial injuries it was reported that on 10/9/2021 R1 was transported to Henry Mayo Newhall ER and diagnosed with Facial injuries (laceration of lip, fracture of nasal bones). When interviewed R1’s family stated that the facility staff called them and reported that staff were pushing R1 in a wheelchair, R1 put her feet down on the floor, launched forward and fell on her face. R1’s family reported that resident was very weak, and they do not believe R1 would be able to launch herself forward. Review of Tri Valley hospice POC/IDG, review dated 10/9/2021 documents records prior to the incident for R1’s mobility as Bed-Bound/Chair-bed transfer, dependent on 6/6 ADL’s, requires repositioning ever 2 hours. 10/5/2021 Home Aid (HA) visit documents R1 carefully transferred to the shower. While conducting review of Resident Care Notes LPA did not observe documentation regarding the incidents. 5/11/2022 Staff interviews revealed R1 was being pushed to the dining room by Staff 1 (S1). Staff did not observe the incident however reported being called for assistance, hearing R1 loudly screaming for help and observing R1 bleeding severely. According to staff interviewed they did not observe footrests on the wheelchair. Staff interviewed also reported questioning S1’s explanation of how the accident occurred and questioned the speed of the wheelchair. According to Staff R1 had a tendency to put her foot down from wheelchair and would be able to walk with 2 staff holding onto her but not sure if R1 could stand on her own. Investigator Kujuwa and LPA Avetisyan attempted to conduct interview with S1 but were unable to do so. Staff # 4 also informed the LPA that incident details were documented on the Crossover report. On 5/11/2022 administrator Cyntia Drachenberg informed the LPA that Crossover reports are only kept for a month. LPA was also informed that information regarding both of the incidents were documented in the company's internal reports which would not be released to the Department.

Based on the information obtained there is sufficient evidence to support the allegations, therefore the allegations of Neglect/Lack of Care and Supervisor Resident 1 (R1) sustained an unexplained injury for which the staff failed to obtain timely medical care and Due to staff neglect Resident 1 (R1) sustained severe facial injuries are deemed Substantiated.

Per California Code of Regulations (CCR), Title 22, see LIC 9099-D for deficiencies cited. An immediate civil penalty of $500 is also assessed. The licensee was informed that a civil penalty might be assessed based on the Health and Safety Code 1569,49(e) or (f), or 1548(e) or (f), 1568.0822(e) or (f).



Exit Interview Conducted / Appeal Rights Discussed / A Copy of the Report Issued.
SUPERVISOR'S NAME: Eva MillerTELEPHONE: (818) 596-4373
LICENSING EVALUATOR NAME: Yelena AvetisyanTELEPHONE: (818) 378-8120
LICENSING EVALUATOR SIGNATURE:

DATE: 08/10/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/10/2022
LIC9099 (FAS) - (06/04)
Page: 4 of 6
Citations on this Visit Report are Under Appeal!

Control Number 31-AS-20211018141211
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: 08/10/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Under Appeal
Type A
08/12/2022
Section Cited
CCR
87469(c)(3)
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Specifically for a terminally ill resident that is receiving hospice services… For emergencies not directly related to the expected course of the resident’s terminal illness, the facility staff shall immediately telephone emergency response (9-1-1). This requirement was not met as evidenced by:
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Licensee/Administrator will schedule vendorized training for all staff regarding Regulation 87469.. Licensee/administrator will submit the credentials of the trainer with the scheduled training dates by 8/12/2022 and completion of training by 9/2/2022.
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 Based on the information obtained during the course of the investigation the licensee/Administrator did not comply with the section cited by failing to call 911 when R1 was experiencing severe pain resulting from an unexplained injury which posed an immediate health and safety and personal rights risk to R1.
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Licenee/Administrator will also Submit Statement of Understanding, detailing how the facility will maintain compliance of Regulation 87469.
Under Appeal
Type A
08/12/2022
Section Cited
CCR
87464(d)
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(d) A facility need not accept a particular resident for care. However, if a facility chooses to accept a particular resident for care, the facility shall be responsible for meeting the resident's needs as identified in the pre-admission appraisal specified in Section 87457....... This requirement was not met as evidenced by:
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Licensee/Administrator will schedule vendorized training for all staff regarding Regulation 87464.. Licensee/administrator will submit the credentials of the trainer with the scheduled training dates by 8/12/2022 and completion of training by 9/2/2022.
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Based on information obtained during the course of the investigation the staff did not comply with the cited section by neglecting to put the footrests on R1’s wheelchair causing R1 to reportedly put foot down, fall forward and sustain severe facial injuries which posed an immediate health and safety and personal rights risk to R1.
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Licenee/Administrator will also Submit Statement of Understanding, detailing how the facility will maintain compliance of Regulation 87464.
Because this violation resulted in resident beingsustaining a serous bodily injury immediate civil penalty in the amount of $500 is issued.
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: Eva MillerTELEPHONE: (818) 596-4373
LICENSING EVALUATOR NAME: Yelena AvetisyanTELEPHONE: (818) 378-8120
LICENSING EVALUATOR SIGNATURE:

DATE: 08/10/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/10/2022
LIC9099 (FAS) - (06/04)
Page: 5 of 6