198320078-5-1-2023-11-AS-MVAO-CUBTC3-20230802143602

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198320078
Report Date: 05/01/2023
Date Signed: 05/01/2023 09:37:33 AM

Substantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

This is an official report of an unannounced visit/investigation of a complaint received in our office on
08/09/2021 and conducted by Evaluator Wendy Gibbs

COMPLAINT CONTROL NUMBER: 11-AS-20210809091814

FACILITY NAME:	OAKMONT OF TORRANCE		FACILITY NUMBER:	198320078
ADMINISTRATOR:	FERNANDEZ, TAMARA		FACILITY TYPE:	740
ADDRESS:	3620 LOMITA BLVD		TELEPHONE:	(424) 338-4457
CITY:	TORRANCE	STATE: CA	ZIP CODE:	90505
CAPACITY:	0	CENSUS: 87	DATE:	05/01/2023
		UNANNOUNCED	TIME BEGAN:	08:15 AM
MET WITH:	Anita Csukardi		TIME COMPLETED:	09:15 AM

ALLEGATION(S):

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Resident suffered an injury to the head while in care.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Wendy Gibbs made an unannounced visit to the facility and was greeted by Administrator Anita Csukardi. LPA conducted a risk assessment prior to entering the facility. Staff informed LPA that the facility has no COVID cases nor do any of the residents or staff members have symptoms. The purpose for today’s visit is to conduct a subsequent visit and deliver the findings pertaining to the above-mentioned allegation.

The investigation consisted of the following:
An initial 10-Day virtual visit was conducted by LPA Don Senaha on 08/10/21 with Administrator (Dollie Bedolla). LPA Senaha requested pertinent service documents and conducted a physical plant inspection for Health & Safety purposes. A separate investigation was conducted by the Department of Social Service Investigator (Robert Kuwaja) which included a review of medical records and interviews with the Corporate Director (Ken Garnet), Administrator (Myla Belson), staff (S1-S3), residents (R1-R3) and witnesses (W1-W2). The Investigator Kuwaja also obtained medical records and reviewed other pertinent documents.

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Eva M Alvarez	TELEPHONE: (323) 629-7047
LICENSING EVALUATOR NAME: Wendy Gibbs	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR SIGNATURE:	DATE: 05/01/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/01/2023

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 11-AS-20210809091814

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: OAKMONT OF TORRANCE	FACILITY NUMBER: 198320078
	VISIT DATE: 05/01/2023

NARRATIVE

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The investigation revealed the following:

Regarding Allegation #1: this investigation revealed Resident (R1) sustained a “blunt head trauma” while under the care at Oakmont of Torrance facility. Review of Resident #1 revealed Resident #1 was bedbound and unable walk or maneuver or bear weight to move around (without assistance from facility staff). During the course of the investigation, interviews conducted with Staff #3 on 08/05/21 at 6:30am, Resident #1 was observed in bed (laying on their side) facing the wall (on the left side) with injuries on their face. Staff #2 reported (between 10:00am to 11:00am), Resident #1 was observed with a bump on the right side of their forehead by Staff #3. Staff #2 called 9-1-1 upon evaluation and Resident #1 was transported to the hospital. There were no witnesses or evidence to show how Resident #1 sustained their injury. (LPA Senaha reviewed medical records revealing Resident #1 was admitted to the hospital at 12:44pm on 08/05/21 with a diagnosis of “facial hematoma”). Lack of supervision given to Resident #1 was a contributing factor that showed how Resident #1 sustained the “blunt head trauma” injury.

Based on the evidence gathered and interviews conducted and records reviewed, the preponderance of evidence standard has been met; therefore, the allegation of NEGLECT/LACK OF SUPERVISION: Resident suffered an injury to the head while in care is found to be SUBSTANTIATED.

According to the California Code of Regulations (Title 22, Division 6, Chapter 8), the following deficiencies had been observed and citation(s) issued (ref. LIC 9099D) civil penalty assessed.

An exit interview has been conducted and a copy of the Complaint Report and Appeal Rights were provided.

SUPERVISOR'S NAME: Eva M Alvarez	TELEPHONE: (323) 629-7047
LICENSING EVALUATOR NAME: Wendy Gibbs	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR SIGNATURE:	DATE: 05/01/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/01/2023

LIC9099 (FAS) - (06/04)

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Control Number 11-AS-20210809091814

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: OAKMONT OF TORRANCE	FACILITY NUMBER: 198320078
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 05/01/2023

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 05/02/2023 Section Cited CCR 87705(c)(4)	1 2 3 4 5 6 7	87705(c)(4) Care of Persons with Dementia: (c) Licensees who accept and retain residents with dementia shall be responsible for ensuring the following: (4) There is an adequate number of direct care staff to support each resident’s physical, social,emotional, safety, and health care needs as identified in their current appraisal. This requirement is not met as evidence by:	1 2 3 4 5 6 7	Licensee shall read: Title 22, Section of "Care of Persons with Dementia" and send a written statement to CCLD by the POC due date. This plan is due to the CCLD/El Segundo ASC Office no later than the POC date.
	8 9 10 11 12 13 14	Based on interviews, observation and records review the facility failed to comply with the section cited above resulting in Lack of supervision. Resident #1 sustained the “blunt head trauma” injury. This posed an immediate Health & Safety risk to resident in care.	8 9 10 11 12 13 14
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

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: Eva M Alvarez	TELEPHONE: (323) 629-7047
LICENSING EVALUATOR NAME: Wendy Gibbs	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR SIGNATURE:	DATE: 05/01/2023

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/01/2023

LIC9099 (FAS) - (06/04)

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