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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197610183
Report Date: 02/02/2022
Date Signed: 02/02/2022 05:08:02 PM

Substantiated


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
01/03/2022 and conducted by Evaluator Angela Panushkina
COMPLAINT CONTROL NUMBER: 31-AS-20220103144127
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: 90DATE:
02/02/2022
UNANNOUNCEDTIME BEGAN:
04:40 PM
MET WITH:Tom Park, AdministratorTIME COMPLETED:
05:00 PM
ALLEGATION(S):
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Facility staff did not give residents their medications correctly.
Facility staff are not adequately trained.
Facility's signage is not properly posted.
INVESTIGATION FINDINGS:
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At 4:40pm Licensing Program Analyst (LPA) Angela Panushkina conducted an unannounced subsequent complaint visit to deliver the finings for the above stated allegations. LPA met with the Administraot, Tom Park, and explained the reason for the visit.

Allegation: Facility staff did not give residents their medications correctly.
On 01/11/22, LPA spoke with the Administrator and a MedTech. LPA also reviewed the facility CSMDR records of the random residents receiving medication assistance by the facility staff. Upon review of the medications LPA observed that three (3) out of three (3) randomly chosen prescribed medications were centrally stored by the facility, however, they were not properly documented on CSMDR. LPA observed R1’s two (2) medications were given as prescribed, however, both medications were not documented on CSMDR. Moreover, LPA observed R2’s prescribed blood pressure medication that was filled on 12/07/21 had only 6 tablets left in a bottle. However, CSMDR records for “Date Started” column was left blank.
Continue on LIC9099-C
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Nichelle GillyardTELEPHONE: (818) 596-4341
LICENSING EVALUATOR NAME: Angela PanushkinaTELEPHONE: 747-230-3364
LICENSING EVALUATOR SIGNATURE:

DATE: 02/02/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/02/2022
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 5
Control Number 31-AS-20220103144127
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: 02/02/2022
NARRATIVE
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 LPA observed R3’s prescribed, narcotic medication was filled on 11/24/21 (in bubble pack) for AM, Noon and PM and was not documented on CSMDR. The Administrator and staff stated that they were not aware of as to why some medications were not documented. When LPA requested to see PRN medication records for the same residents, LPA was informed that PRN records were kept in a main resident’s file, per previous MedTech’s request.

LPA informed the Administrator that all medication related documents shall be kept in one file to ensure an accuracy of a proper documentation and requested that all staff handling medication shall take/re-take medication training. Based on interviews and observations made by LPA on 1/11/22 at 11:28am this allegation is deemed Substantiated.

Allegation: Facility staff are not adequately trained.
S1 stated that their training on passing medications consisted of a brief explanation from the outgoing staff member about when to give AM vs PM medications. At 11:50am LPA asked the administrator for proof of S1's training and was given a one page paper that listed hours for various topics, including 6hrs for medications, but did not specify the day the training was given or by whom. Based on interviews and LPA observations this allegation is deemed Substantiated.

Allegation: Facility's signage is not properly posted
On an initial visit, made on 1/11/22, LPA was able to tour the facility at 11:09am and interview the Administrator. While conducting a tour of the common areas, Administrator stated that the Ombudsman’s poster is placed on a second floor, in an activity room. LPA was able to observe the Ombudsman's poster, along with all licensing posters, posted in a frame. LPA requested that all posters that contain information on the appropriate reporting agency in case of a complaint or emergency shall be posted in the main entryway of the facility. Based on the information obtained through interviews and observation this allegation is deemed Substantiated.

Exit interview conducted, copy of report and appeal rights provided to the Administrator.
SUPERVISOR'S NAME: Nichelle GillyardTELEPHONE: (818) 596-4341
LICENSING EVALUATOR NAME: Angela PanushkinaTELEPHONE: 747-230-3364
LICENSING EVALUATOR SIGNATURE:

DATE: 02/02/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/02/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 5
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
01/03/2022 and conducted by Evaluator Angela Panushkina
COMPLAINT CONTROL NUMBER: 31-AS-20220103144127

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: DATE:
02/02/2022
UNANNOUNCEDTIME BEGAN:
04:40 PM
MET WITH:Tom Park, AdministratorTIME COMPLETED:
05:00 PM
ALLEGATION(S):
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Facility does not serve nutritious foods to residents.
INVESTIGATION FINDINGS:
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At 4:50pm Licensing Program Analyst (LPA) Angela Panushkina conducted an unannounced subsequent complaint visit to deliver the finings for the above stated allegations. LPA met with the Administraot, Tom Park, and explained the reason for the visit.

Allegation: Facility does not serve nutritious foods to residents.
During the visit on 1/11/22 at 12:08pm, LPA was unable to interview residents due to a COVID-19 outbreak within the facility. LPA toured the kitchen area with the Administrator and interviewed Lead Server. LPA was informed that the facility hallway was split into two sections (A & B) to organize the “hot” meal delivery. Lead Server informed LPA that the night before, the kitchen staff gets the BLD (breakfast, lunch and dinner) orders for the next day. If no special orders placed, then the facility provides its regular meal. LPA reviewed the facility menu for that week and was able to observe nutritious lunch that was ready to be taken to resident’s room. Based on the information obtained during the course of the investigation the allegation is Unsubstantiated.
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Nichelle GillyardTELEPHONE: (818) 596-4341
LICENSING EVALUATOR NAME: Angela PanushkinaTELEPHONE: 747-230-3364
LICENSING EVALUATOR SIGNATURE:

DATE: 02/02/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/02/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 3 of 5
Control Number 31-AS-20220103144127
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: 02/02/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
02/09/2022
Section Cited
CCR
87465(h)(6)A-F
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87465 Incidental Medical and Dental Care
(h) The following requirements shall apply to medications which are centrally stored: (6) The licensee shall be responsible for assuring that a record of centrally stored prescriptions...

This requirement is not met as evidenced by:
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Administrator agreed to schedule vendorized training for all staff by 02/9/22 and submit to CCL the vendor information and scheduled date of training. Training certifications to be submitted to CCL upon completion by 02/09/22
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Based on record reviews and interviews, licensee did not comply with the section above, as facility staff handling medications were not properly documenting prescribed and PRN medications on CSMDR, which poses a potential health and safety rist to residents in care.
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Type B
02/09/2022
Section Cited
HSC
1569.69(a)(1)
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§1569.69 Employees assisting residents with self-administration of medication; training requirements (1) In facilities licensed to provide care for 16 or more persons, the employee shall complete 24 hours of initial training....

This requirement is not met as evidenced by:
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Administrator agreed to schedule vendorized training for all staff by 02/3/22 and submit to CCL the vendor information and scheduled date of training. Training certifications to be submitted to CCL upon completion by 02/03/22.
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Based on record review and interviews, licensee failed to ensure staff were provided the required 24 hours of initial training, which poses 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: Nichelle GillyardTELEPHONE: (818) 596-4341
LICENSING EVALUATOR NAME: Angela PanushkinaTELEPHONE: 747-230-3364
LICENSING EVALUATOR SIGNATURE:

DATE: 02/02/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/02/2022
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 31-AS-20220103144127
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: 02/02/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
02/09/2022
Section Cited
CCR
1569.33
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Posting requirements 1569.33(h)(2)
(2) Each residential care facility for the elderly shall post this poster in the main entryway of its facility.

This requirement was not met as evidenced by
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Administrator agreed to remove the Ombudsman’s poster from the activity room (on a second floor) and post it in the main entryway (on a first floor).
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Based on observations made by LPA on 1/11/22 at 11:09am, the licensee did not comply with the section cited above, in posting the Ombudsman’s poster in the main entryway, which posed a potential health, safety risk to persons 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: Nichelle GillyardTELEPHONE: (818) 596-4341
LICENSING EVALUATOR NAME: Angela PanushkinaTELEPHONE: 747-230-3364
LICENSING EVALUATOR SIGNATURE:

DATE: 02/02/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/02/2022
LIC9099 (FAS) - (06/04)
Page: 5 of 5