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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198320250
Report Date: 01/27/2024
Date Signed: 01/27/2024 10:22:44 AM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245
This is an official report of an unannounced visit/investigation of a complaint received in our office on
01/17/2023 and conducted by Evaluator Ernand Dabuet
PUBLIC
COMPLAINT CONTROL NUMBER: 11-AS-20230117153703
FACILITY NAME:OAKMONT OF TORRANCEFACILITY NUMBER:
198320250
ADMINISTRATOR:BELSON, MYLAFACILITY TYPE:
740
ADDRESS:3620 LOMITA BLVDTELEPHONE:
(424) 376-3300
CITY:TORRANCESTATE: CAZIP CODE:
90905
CAPACITY:126CENSUS: 86DATE:
01/27/2024
UNANNOUNCEDTIME BEGAN:
09:07 AM
MET WITH:Cortney Holmes - Activity DirectorTIME COMPLETED:
10:38 AM
ALLEGATION(S):
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Resident wandered away from facility due to lack of supervision resulting in hypothermia.
Staff did not notify police of missing resident.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Ernand Dabuet made an unannounced visit to the facility and was greeted by Activity Director (S10: Cortney Holmes). LPA conducted a risk assessment prior to entering the facility and observed COVID-19 protocol. (S10) informed LPA that the facility has no COVID cases nor do any of the residents or staff have symptoms. The purpose for today’s visit is to conduct a subsequent visit and deliver the findings pertaining to the above-mentioned allegations.

An initial 10-Day visit was conducted by LPA Jeremiah Randle on 01/19/23 with Executive Director/Administrator (S1: Julius Osorio). During this visit, LPA conducted a tour of the facility’s physical plant and observed the residents in care for health and safety purposes. A separate investigation was conducted by the Department’s Investigation Bureau by Investigator (Dennis Seng) which included medical records review; interviews with hospital personnel, local law enforcement, Fire/EMT personnel, and facility staff.
(Evaluation Report continues LIC 9099-C)
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Janae HammondTELEPHONE: (424) 544-1027
LICENSING EVALUATOR NAME: Ernand DabuetTELEPHONE: (323) 629-5526
LICENSING EVALUATOR SIGNATURE:

DATE: 01/27/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/27/2024
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 4
Control Number 11-AS-20230117153703
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245
FACILITY NAME: OAKMONT OF TORRANCE
FACILITY NUMBER: 198320250
VISIT DATE: 01/27/2024
NARRATIVE
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During today’s visit, LPA Ernand Dabuet conducted a subsequent visit and delivered the findings. LPA/RA Elizabeth Ceniceros reviewed pertinent documents: Facility Staff Roster & Work Schedules and Residents’ Roster (January 2023), Unusual Incident Report (dated 01/16/23), Facility Profile, Personnel Report Summary, Facility Sketch (1st & 2nd Floors w/Apartment Numbers); Torrance P.D. Call Detail Report (dated 01/16/23) with photographs; Resident #1’s I.D. Information form (dated 12/21/21), Power of Attorney (dated 06/17/10), Admission Agreement (dated 01/04/21), Physician’s Report (dated 09/20/22), Appraisal Needs & Services Plan (dated 11/24/21), Resident Care Notes (dated 01/13/23), Personal Rights (dated 12/21/21), and Medication Administration Records (December 2022 & January 2023).

INVESTIGATION REVEALED THE FOLLOWING:

Allegation: Resident wandered away from facility due to lack of supervision resulting in hypothermia.

It is alleged Resident #1 wandered away from the facility resulting in hospitalization for Hypothermia.

Interviews conducted with facility Staff and residents revealed the following: According to interviews conducted and records reviewed Resident #1 is diagnosed with Dementia and has a history of wandering. According to A1, R1 wears a wander bracelet but it was removed on the day of the incident. On 01/15/23 (approximately 10:00 p.m.), Staff #8 (S8: Christina Guilo, Caregiver) conducted their routine, nightly rounds and had not observed Resident #1 in their room. Staff #8 proceeded with their routine checks and making their rounds and failed to notify Staff #4 (S4: Latasha Ramirez, Med Tech) of Resident #1 missing from their room. Staff #8 didn’t advise Staff #4 until (approximately) 11:00 p.m. on 01/15/23. Staff #4 and Staff #8 began a search for Resident #1 inside the facility; but they failed to look outside the exterior of the facility due to excessive rain. Staff #4 notified Staff #5 (S5: Jacklyn Lefeiloai, Resident Care Coordinator), Executive Director (A1: Julius Osorio), Staff #9 (S9: Courtney Clark, Health Services Specialist), and Resident #1’s Power of Attorney (W1: Family Member) of the missing resident (approximately) 3:30 a.m. on 01/16/23. Once permission was granted by management (A1), Staff #4 called 9-1-1 to make the notification to local law enforcement agency. Within that time, a passerby came to the facility to advise them that there was an elderly person outside in the rain. Resident #1 had been found supine in the bushes (near the sidewalk) in front of the facility (approximately) 4:00 a.m. on 01/16/23. Resident #1 was transported (via ambulance) and admitted to Torrance Memorial Hospital ER for severe hypothermia for which the resident was in ICU. Resident #1 was discharged from the hospital on or about 01/19/23 and did not return to the facility – pending availability in the Memory Care Unit.

(Evaluation Report continues LIC 9099-C)

SUPERVISOR'S NAME: Janae HammondTELEPHONE: (424) 544-1027
LICENSING EVALUATOR NAME: Ernand DabuetTELEPHONE: (323) 629-5526
LICENSING EVALUATOR SIGNATURE:

DATE: 01/27/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/27/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 4
Control Number 11-AS-20230117153703
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245
FACILITY NAME: OAKMONT OF TORRANCE
FACILITY NUMBER: 198320250
VISIT DATE: 01/27/2024
NARRATIVE
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Based on the evidence gathered, interviews conducted, and records reviewed, the preponderance of evidence standard has been met; therefore, the allegation of NEGLECT/ LACK OF SUPERVISION: Resident wandered away from facility due to lack of supervision resulting in hypothermia is found to be SUBSTANTIATED.

According to the California Code of Regulations (Title 22, Division 6, Chapter 8), the following deficiency has been observed and a citation issued (ref. LIC 9099D) and Civil Penalty assessed for $500 dollars.

Allegation #2: Staff did not notify police of missing resident.

Interview and records review conducted revealed the following: this investigation revealed during an interview with Staff #8 (S8: Cristina Guico, Caregiver) admitted not reporting to Staff #4 (S4: Latasha Ramirez, Med Tech) that Resident #1 was missing from their room during their routine round checks (approximately) 10:00 p.m. on 01/15/23. Staff #4 admitted that they began searching for Resident #1 inside the facility (approximately) 11:00 p.m. on 01/15/23 once Staff #8 advised facility staff member; but, they failed to look outside the exterior of the facility due to excessive rain. On 01/16/23, beginning at 3:30 a.m., Staff #4 began notifying (via telephone) Staff #5 (S5: Jacklyn Lefeiloai, Resident Care Coordinator), Executive Director (A1: Julius Osorio), Staff #9 (S9: Courtney Clark, Health Services Specialist), and Resident #1’s Power of Attorney (W1: Family Member) of the missing resident. Once permission was granted by management (A1) to call 9-1-1, Staff #4 made notification of a missing person report to local law enforcement. IB investigator obtained copies of the Torrance Police Department call logs and there is no record of the facility called to report the incident.

Based on the evidence gathered, interviews conducted, and records reviewed, the preponderance of evidence standard has been met; therefore, the allegation of REPORTING REQUIREMENTS: Staff did not notify police of missing resident is found to be SUBSTANTIATED.

According to the California Code of Regulations (Title 22, Division 6, Chapter 8), the following deficiency has been observed and citation issued (ref. LIC 9099D).

An exit interview has been conducted and a copy of the Complaint Report and Appeal Rights were provided to the Activity Director Cortney Holmes.

SUPERVISOR'S NAME: Janae HammondTELEPHONE: (424) 544-1027
LICENSING EVALUATOR NAME: Ernand DabuetTELEPHONE: (323) 629-5526
LICENSING EVALUATOR SIGNATURE:

DATE: 01/27/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/27/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 4
Control Number 11-AS-20230117153703
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245

FACILITY NAME: OAKMONT OF TORRANCE
FACILITY NUMBER: 198320250
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/27/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
01/29/2024
Section Cited
CCR
87466
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87466 Observation of the Resident: The licensee shall ensure that residents are regularly observed for changes in physical, mental, emotional, and social functioning, and that appropriate assistance is provided...

This requirement is not met as evidenced by:
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Licensee/Administrator shall read: Title 22, Section "Observation of the Resident" and send a written statement to CCLD. The Plan of Correction (POC) is due to the CCLD/El Segundo ASC Regional Office no later than the POC date on 01/29/24. Please fax: 424-544-1016.
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Based on observation, interviews and record reviews, Resident #1 wandering away from the facility resulting in hospitalization for hypothermia. This violation which posed a immediate health and safety to residents in care.
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*IMMEDIATE CIVIL PENALTY*
Deficiency Dismissed
Type A
01/29/2024
Section Cited
CCR
87211(a)(D)
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87211(a)(D) Reporting Requirements: (a) Each licensee shall furnish to the
licensing agency such reports as the Department may require, including, but not limited to, the following: (D) Any incident which threatens the welfare, safety or health of any resident...or unexplained absence of any
resident.
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Licensee/Administrator shall read: Title 22, Section 87211 "Reporting Requirements” and send a written statement to CCLD. The Plan of Correction (POC) is due to the CCLD/El Segundo ASC Regional Office no later than the POC date on 01/29/24. Please fax: 424-544-1016.
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This requirement is not met as evidenced by:
Based on observation, interviews, and record reviews. Facility staff failed to call 9-1-1 and report to local law enforcement that Resident #1 had been missing from the facility on 01/16/23 from 10:00 p.m. to 01/17/23 at 4:00 a.m. This violation which posed a immediate health and safety 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: Janae HammondTELEPHONE: (424) 544-1027
LICENSING EVALUATOR NAME: Ernand DabuetTELEPHONE: (323) 629-5526
LICENSING EVALUATOR SIGNATURE:

DATE: 01/27/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/27/2024
LIC9099 (FAS) - (06/04)
Page: 4 of 4