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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197610183
Report Date: 06/24/2024
Date Signed: 06/24/2024 02:00:29 PM


Document Has Been Signed on 06/24/2024 02:00 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS S.ASC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364



FACILITY NAME:OAKMONT OF VALENCIAFACILITY NUMBER:
197610183
ADMINISTRATOR:MYLA BELSONFACILITY TYPE:
740
ADDRESS:24070 COPPER HILL DRIVETELEPHONE:
(661) 568-6080
CITY:VALENCIASTATE: CAZIP CODE:
91354
CAPACITY:144CENSUS: 98DATE:
06/24/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Rosa EspinozaTIME COMPLETED:
02:15 PM
NARRATIVE
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Licensing Program Analyst (LPA) Tuesday Cabiness conducted a Case Management, in conjunction with complaint control # (31-AS-20240618151354). According to information obtained during the preliminary of the investigation, it was reported that resident #1 (R1) had sustained multiple falls at the facility. LPA reviewed incident reports submitted by the facility, and LPA observed that one SIR (special incident report) was submitted pertaining to R1 falling on 06/17/2024. It was revealed to LPA that R1 fell twice, either once on 06/16/2024 or twice on 06/17/2024. The initial SIR reported, R1 fell once on 06/17/2024. Therefore, based on documentation and interviews, the facility failed to report R1 falling twice. This is a potential health and safety risk to residents in care. Citation issued and incident submitted to LPA during visit. POC cleared.

Exit interview, citation, appeals, and copy of report provided.
SUPERVISOR'S NAME: Troy AgardTELEPHONE: (818) -596-4334
LICENSING EVALUATOR NAME: Tuesday CabinessTELEPHONE: (818) 299-4975
LICENSING EVALUATOR SIGNATURE:
DATE: 06/24/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/24/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2


Document Has Been Signed on 06/24/2024 02:00 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS S.ASC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364


FACILITY NAME: OAKMONT OF VALENCIA
FACILITY NUMBER: 197610183

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/24/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
06/28/2024
Section Cited
CCR
87211(a)(1)

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Reporting requirements; (a) Each licensee shall furnish to the licensing agency such reports as the Department may require, including, but not limited to, the following:(1)A written report shall be submitted to the licensing agency...and to the person responsible for the resident within seven days
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Executive Director (ED) will submit incident report for fall dated on 06/16/2024. During visit, LPA received SIR, and POC is cleared.
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...and disposition of the case. This requirement was not met evidenced; based on documentation and interviews, facility submited one SIR for R1 when there were multiple falls. This is 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: Troy AgardTELEPHONE: (818) -596-4334
LICENSING EVALUATOR NAME: Tuesday CabinessTELEPHONE: (818) 299-4975
LICENSING EVALUATOR SIGNATURE:
DATE: 06/24/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/24/2024
LIC809 (FAS) - (06/04)
Page: 2 of 2