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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197610183
Report Date: 10/30/2024
Date Signed: 10/30/2024 03:20:38 PM

Document Has Been Signed on 10/30/2024 03:20 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: 103DATE:
10/30/2024
TYPE OF VISIT:Case Management - Legal/Non-complianceUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
02:00 PM
MET WITH:Myla BelsonTIME VISIT/
INSPECTION COMPLETED:
03:30 PM
NARRATIVE
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Licensing Program Analyst (LPA) Tuesday Cabiness conducted a case management visit in regards to an SIR (Special Incident Report) that was submitted pertaining to resident #1 (R1) who was administered wrong medication. LPA met with Executive Director Myla Belson, who was informed the reason of the visit, and who reported to LPA, that staff # 1 (S1) accidentally administered the wrong medication to R1. Administrative staff were immediately notified. Power of Attorney (POA) was also notified the same day. R1 was sent to the hospital for evaluation, and was returned to the community, with no documentation of any medical or adverse action of the wrong medication. LPA interviewed staff and Executive Director.

The ED reported the incident to Licensing with a SIR. During today's visit, ED reported that the facility and corporate implemented additional medication training, by the Regional Licensed registered nurses that conducted training on October 28, 2024.

LPA has determined that further review with the Regional Manager and Licensing Program Manager needs to be followed up at a later date and time. LPA will conduct an additional case management pertaining to the incident of medication error for resident # 1(R1).

Citation issued, appeal right, exit interview, and copy of report provided to ED.
SUPERVISORS NAME: Troy Agard
LICENSING EVALUATOR NAME: Tuesday Cabiness
LICENSING EVALUATOR SIGNATURE: DATE: 10/30/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/30/2024
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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Document Has Been Signed on 10/30/2024 03:20 PM - It Cannot Be Edited


Created By: Tuesday Cabiness On 10/30/2024 at 02:44 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: 10/30/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
10/30/2024
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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An in-service re-training was conducted with medication technicians on 10/28/2024. LPA received by the training record. It was reported that the ED Myla Belson, Rickie McGregor (LVN) and Siliva Anaya (Regional Health Services Director) were present and attended the training.
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This requirement was not met as evidence by: It was reported to Licensing staff #1 administered the wrong medication to resident #1. This poses as an immediate health and safety risk to residents in care.
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POC will be cleared, but further review will be required upon meeting with management pertaining to medication errors. A follow-up visit will take place at a later date and time.

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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 Agard
LICENSING EVALUATOR NAME:Tuesday Cabiness
LICENSING EVALUATOR SIGNATURE:
DATE: 10/30/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/30/2024


LIC809 (FAS) - (06/04)
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