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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198320078
Report Date: 01/28/2022
Date Signed: 01/28/2022 07:45:17 PM

Document Has Been Signed on 01/28/2022 07:45 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
CCLD Regional Office, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME:OAKMONT OF TORRANCEFACILITY NUMBER:
198320078
ADMINISTRATOR:MYLA BELSONFACILITY TYPE:
740
ADDRESS:3620 LOMITA BLVDTELEPHONE:
(424) 338-4457
CITY:TORRANCESTATE: CAZIP CODE:
90505
CAPACITY: 126CENSUS: 86DATE:
01/28/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
01:19 PM
MET WITH:Administrator Myla BelsonTIME COMPLETED:
03:15 PM
NARRATIVE
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LPA received a phone call from Administrator Myla Belson of an incident regarding a medication error for Resident (R1-R2) on 01/28/2022. LPA spoke to Administrator Myla Belson to discuss the issues of the medication error. LPA determined there needs to be a Case Management regarding this incident.

01/28/22 Licensing Program Analyst (LPA) Don Senaha initiated a Case Management – incident report visit. LPA was met by Administrator Myla Belson and Health Services Director Jennifer Flores and explained the purpose of today’s visit.

A plant inspection of the facility was conducted.

Administrator Myla Belson stated resident (R1) was given an additional medication not prescribed to resident (R1) by the doctor. Resident (R2) was not given her medication as prescribed by the doctor. Staff (S2) released the incorrect medication bubble pack to resident’s (R1) family which belonged to resident (R2). Resident (R2) was now missing her morning medication due to awaiting medication refill from 01/09/2022-01/27/2022.

Resident (R1) was out of the community from 01/07/2022-01/26/2022.

LPA observed the medication process when a resident is taken out of the facility by family members. Staff (S1) stated the family is given a Medication Release Record form (611a) which lists the medication and dose to be given. Staff (S1) stated the 611a is explained to the family members. Staff (S1) stated the staff releasing the medication is responsible for the list and ensuring all medications match the Medication Administration Record (MAR) prior to explaining and giving the 611a to the family members.
SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Don Senaha
LICENSING EVALUATOR SIGNATURE: DATE: 01/28/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/28/2022
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 01/28/2022 07:45 PM - It Cannot Be Edited


Created By: Don Senaha On 01/28/2022 at 01:45 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
, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: OAKMONT OF TORRANCE
FACILITY NUMBER: 198320078

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/28/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
01/28/2022
Section Cited
CCR
87468.2(a)(2)

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87468.2 Additional Personal Rights of Residents in Privately Operated Facilities (a) In addition to the rights listed in Section 87468.1... of the following personal rights: (4) To care, supervision, and services that meet their individual needs...to meet their needs. This requirement is not met as evidenced by
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Administrator completed an in-service training on 01/27/2022. LPA obtained copy. Administrator also conducting a Med Cart audit to be completed by 01/28/2022. Relias training with medication administration also required by med techs due by 02/15/2022.
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Based on observation and interviews, the licensee did not ensure the medications were following the doctor's prescription orders, which poses an immediate health and 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:Eva M Alvarez
LICENSING EVALUATOR NAME:Don Senaha
LICENSING EVALUATOR SIGNATURE:
DATE: 01/28/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/28/2022


LIC809 (FAS) - (06/04)
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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
CCLD Regional Office, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME: OAKMONT OF TORRANCE
FACILITY NUMBER: 198320078
VISIT DATE: 01/28/2022
NARRATIVE
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LPA obtained a copy of the 611a and it did not match the medications for resident (R1) per the doctor prescriptions or the MAR. Staff (S2) included an additional unprescribed medication in the 611a – Risperdone for resident (R1).

Based on interviews, observation, and record reviews the licensee violated the California Code Regulations (CCR) of Title 22, Division 6, Chapter 8.

A deficiency was issued and an exit interview is conducted with Myla Belson. A copy of this report is provided along with the appeal rights.
SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Don Senaha
LICENSING EVALUATOR SIGNATURE:

DATE: 01/28/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/28/2022
LIC809 (FAS) - (06/04)
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