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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197610183
Report Date: 03/27/2025
Date Signed: 03/27/2025 04:46:14 PM

Document Has Been Signed on 03/27/2025 04:46 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/
DIRECTOR:		MYLA BELSONFACILITY TYPE:
740
ADDRESS:24070 COPPER HILL DRIVETELEPHONE:
(661) 568-6080
CITY:VALENCIASTATE: CAZIP CODE:
91354
CAPACITY: 144CENSUS: 102DATE:
03/27/2025
TYPE OF VISIT:Case Management - Legal/Non-complianceUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:00 AM
MET WITH:Myla BelsonTIME VISIT/
INSPECTION COMPLETED:
05:00 PM
NARRATIVE
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Licensing Program Analyst (LPA) Tuesday Cabiness conducted a case management visit regarding a Special Incident Report (SIR) that was submitted concerning eight (8) residents who were not administered their prescribed medication. LPA met with Executive Director Myla Belson and informed her the purpose of the visit. According to the SIR, the facility’s medication protocols were reviewed, and the error was identified and addressed promptly. Administrative staff immediately notified the residents' families and primary physicians, and all affected residents were placed under immediate observation. It was reported to LPA that no adverse effects were observed. LPA interviewed staff and the Executive Director and reviewed resident records.

Notably, the facility was placed on a non-compliance plan dated 12/15/2022. Additionally, the reports cited the facility for violations related to reporting requirements, resident injuries, unexplained falls, and medication errors, including a questionable death. It was further documented that legal action maybe taken against the facility.

Since the date of the Non-Compliance Conference (NCC) on 12/15/2022, and up to today's date, the facility has received six (6) complaints and five (5) case management visits. Two (2) of these visits, on 04/07/2023 and 10/30/2024, involved residents being administered the wrong medication. Another case management visit on 06/24/2024 was related to a failure to report.

During today’s visit on 03/27/2025, involved eight (8) residents who missed their daily medication. According to the information obtained, on 03/17/2025, the disbursement of noon medication was missed and not given to residents. Staff identified the error and notified the appropriate administrative staff.

NAME OF LICENSING PROGRAM MANAGER: Troy Agard
NAME OF LICENSING PROGRAM ANALYST: Tuesday Cabiness
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 03/27/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/27/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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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
VISIT DATE: 03/27/2025
NARRATIVE
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Based on today's findings, LPA will recommend that the initial non-compliance plan dated 12/15/2022 be extended for an additional two (2) years and that another (NCC) meeting be scheduled at the local regional office (RO). LPA will discuss recommendations with management, and further review is required at this time and LPA will follow up with the ED.

Citation issued, civil penalty assessed, appeal rights, and copy of report provided to ED.

NAME OF LICENSING PROGRAM MANAGER: Troy Agard
NAME OF LICENSING PROGRAM ANALYST: Tuesday Cabiness
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 03/27/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/27/2025
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 03/27/2025 04:46 PM - It Cannot Be Edited


Created By: Tuesday Cabiness On 03/27/2025 at 02:56 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

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

FACILITY NAME: OAKMONT OF VALENCIA
FACILITY NUMBER: 197610183

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/27/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
03/28/2025
Section Cited
CCR
87411(d)(4)

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87411 Personnel Requirements-General; (d) All personnel shall be given on the job training... This training and/or related experience shall provide knowledge of and skill in the following...Knowledge required to safely assist with prescribed medications which are self-administered...
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Executive Director (ED) Myla Belson will discuss with the Regional team in regards to training and safeguard implements for staff pertaining to administration of medication and other related training.
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This requirement was not met as evidence by: based on a SIR submitted to Licensing, it was reported (8) residents missed their daily medication. This poses as an immediate health and safety risk to residents in care.
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Type A
03/28/2025
Section Cited
CCR87465(c)(2)

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Incidental Medical and Dental Care:If the resident's physician has stated in writing that the resident is unable to determine his/her own need for nonprescription PRN medication but can communicate his/her symptoms clearly, facility staff...shall be permitted to assist...
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Executive Director (ED) Myla Belson will discuss with the Regional team in regards to training and safeguard implements for staff pertaining to administration of medication and other related training.
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following requirements are met:(2) Once ordered by the physician the medication is given according to the physician's directions. This requirement was not met, evidenced by, based on the SIR was submitted: (8) residents were not giving medication according to doctor's orders. This is an immediate 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.
Troy Agard
NAME OF LICENSING PROGRAM MANAGER:
Tuesday Cabiness
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 03/27/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/27/2025


LIC809 (FAS) - (06/04)
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