198320250-1-15-2025-11-AS-EMAZ-DDSUVM-20250211145523

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198320250
Report Date: 01/15/2025
Date Signed: 01/15/2025 05:09:04 PM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 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
01/07/2025 and conducted by Evaluator Wendy Gibbs

COMPLAINT CONTROL NUMBER: 11-AS-20250107091829

FACILITY NAME:	OAKMONT OF TORRANCE		FACILITY NUMBER:	198320250
ADMINISTRATOR:	MATTHEW RYAN		FACILITY TYPE:	740
ADDRESS:	3620 LOMITA BLVD		TELEPHONE:	(424) 376-3300
CITY:	TORRANCE	STATE: CA	ZIP CODE:	90505
CAPACITY:	126	CENSUS: 83	DATE:	01/15/2025
		UNANNOUNCED	TIME BEGAN:	08:30 AM
MET WITH:	Angelie Pasa		TIME COMPLETED:	05:00 PM

ALLEGATION(S):

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Staff did not folow advanced directives and requests regarding resuscitative measures

INVESTIGATION FINDINGS:

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On 01/15/2025, the department conducted an unannounced complaint visit to the facility listed above. The department met with Health Service Director, Angelie Pasa, and the purpose of today’s visit was explained.

During today’s visit the department conducted a facility tour, interviewed Staff S1-S6, and received documents pertinent to the investigation. The following documents were received and reviewed: Staff Roster, Resident Roster, Resident Face Sheet, Resident Information Form, Physician Orders for Life-Sustaining Treatment (POLST), Physician’s Report (LIC602A), Physician’s Orders, and Follow Up Encounter Notes from Senior Doc CA.

The investigation revealed the following:

Continued On LIC9099-C

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Wendy Gibbs
LICENSING EVALUATOR SIGNATURE:	DATE: 01/15/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/15/2025

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 3

Control Number 11-AS-20250107091829

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

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

FACILITY NAME: OAKMONT OF TORRANCE	FACILITY NUMBER: 198320250
	VISIT DATE: 01/15/2025

NARRATIVE

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Allegation: Staff did not follow advanced directives and requests regarding resuscitative measures.
The complaint allegation alleges that staff did not perform Cardiopulmonary Resuscitation (CPR) or use an Automated External Defibrillator (AED) when a resident was found without a pulse and not breathing.
During the visit, the department conducted a file review and received and reviewed a copy of resident R1’s POLST form. The department observed on the form in section A Cardiopulmonary Resuscitation (CPR): If a patient has no pulse and is not breathing, R1 had indicated Do Not Attempt Resuscitation/DNR (Allow Natural Death). Additionally, the department received and reviewed a copy of Follow Up Encounter Notes from Senior Doc CA when R1’s Selective Code and Full Code were discussed with the Medical Power of Attorney and a medical professional. On 05/02/2023 the POLST was filled out and indicated A. Do Not Attempt Resuscitations/DNR (Allow Natural Death). The department observed on R1’s Face Sheet that the Code Status is DNAR/Do Not Attempt Resuscitation.
During interviews with Staff S1-S6, were asked if R1’s POLST was followed on 01/05/2025, six (6) out of six (6) stated they knew R1 was a DNAR and did not try to resuscitate.
The department interviewed the Nurse Practitioner that has been tending to R1 regularly, the Nurse Practitioner confirmed that the POLST on file was according to R1’s and his family’s wishes.

SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Wendy Gibbs
LICENSING EVALUATOR SIGNATURE:	DATE: 01/15/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/15/2025

LIC9099 (FAS) - (06/04)

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Control Number 11-AS-20250107091829

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

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

FACILITY NAME: OAKMONT OF TORRANCE	FACILITY NUMBER: 198320250
	VISIT DATE: 01/15/2025

NARRATIVE

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During the course of the investigation, LPA was unable to find evidence to support the allegation. Although the allegation may have happened or is valid, there is no preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is unsubstantiated.

The department did not observe or cite any deficiencies.

An exit interview was conducted with Health Service Director, Angelie Pasa and a copy of this report was provided.

SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Wendy Gibbs
LICENSING EVALUATOR SIGNATURE:	DATE: 01/15/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/15/2025

LIC9099 (FAS) - (06/04)

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