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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:
SUPERVISORS NAME: Eva Miller
LICENSING EVALUATOR NAME: Yelena Avetisyan
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.
SUPERVISORS NAME: Eva Miller
LICENSING EVALUATOR NAME: Yelena Avetisyan
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:Assaad Zeid, Administrator TIME COMPLETED:
02:00 PM
ALLEGATION(S):
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Due to staff neglect Resident 1 (R1) sustained severe facial injuries.
INVESTIGATION FINDINGS:
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This is an Amendment to the original report issued 08/10/2022, to remove one allegation due to change in findings.

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

Continue on LIC9099-C
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Angela Panushkina
LICENSING EVALUATOR SIGNATURE:

DATE: 06/30/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/30/2026
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 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.

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.

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. Continue on LIC9099-C

SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Angela Panushkina
LICENSING EVALUATOR SIGNATURE:

DATE: 06/30/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/30/2026
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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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.
SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Angela Panushkina
LICENSING EVALUATOR SIGNATURE:

DATE: 06/30/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/30/2026
LIC9099 (FAS) - (06/04)
Page: 4 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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/10/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Deficiency Dismissed
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.
Request Denied
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.
SUPERVISORS NAME: Eva Miller
LICENSING EVALUATOR NAME: Yelena Avetisyan
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