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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198320250
Report Date: 03/14/2024
Date Signed: 03/14/2024 08:26:16 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, 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
11/28/2022 and conducted by Evaluator Ernand Dabuet
PUBLIC
COMPLAINT CONTROL NUMBER: 11-AS-20221128132320
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: 89DATE:
03/14/2024
UNANNOUNCEDTIME BEGAN:
08:58 AM
MET WITH:Judith Uy-Vllaruz TIME COMPLETED:
10:36 AM
ALLEGATION(S):
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Resident sustained a fall while in care.
Staff did not seek timely medical attention for a resident.
Resident developed multiple pressure injuries while in care.
INVESTIGATION FINDINGS:
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On 03/14/24, Licensing Program Analysts (LPAs) Ernand Dabuet and Troy Watson conducted a subsequent unannounced complaint investigation visit for the allegations listed above. Today’s complaint investigation was conducted with administrator Judith Uy-Villaruz. The purpose of the visit is to deliver the findings for this complaint.

The investigation consisted of the following: LPA obtained copies of the roster for Resident and Staff. Interviews with administrator (A#1), staff #1-3 (S1-S3), residents #1-#9 (R1-R9), and witness #1 (W1). A reviewed of (R1's) Service records, Hospice records, and Medical records, and other pertinent documents associated with this complaint. A tour of the facilty conducted on 12/09/22, 03/01/24, 03/14/24.

(Evaluation Report continues LIC 9099-C)
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Janae HammondTELEPHONE: (424) 544-1027
LICENSING EVALUATOR NAME: Ernand DabuetTELEPHONE: (323) 629-5526
LICENSING EVALUATOR SIGNATURE:

DATE: 03/14/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/14/2024
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 5
Control Number 11-AS-20221128132320
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: 03/14/2024
NARRATIVE
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INVESTIGATION REVEALED THE FOLLOWING:

Allegation #1: Resident sustained a fall while in care.

The details of the complaint alleged resident #1 (R1) sustained a fall due to lack of care. The complainant reported (R1) had a fall on 11/24/22. The complainant did not have further information on this matter.

(R1) transitioned from Atlantic Memorial Long Beach a skilled nursing facility to Oakmont at Torrance an assisted living facility on 11/19/22. Upon arrival, (R1) was immediately placed on hospice care with Beacon Hospice Inc. on 11/19/22. (R1) was considered a fall risk and a fall management plan was in place with hospice (dated: 03/08/24) and an Individualized Service Plan with the facility (dated: 08/10/22). The Fall Plan provided instructions to educate caregivers on how to prevent falls, fall precautions, and safety precautions, minimize fall risk factors, and interventions to manage falls.

On 11/25/22 at 4:30 am, (R1) had an unwitnessed fall and was discovered by a facility staff while doing routine rounds. (R1) was assisted by the staff who was found lying on the floor in (R1’s) room with a head injury. Facility progress notes (dated: 11/25/22) and hospice visit notes (dated: 11/25/22), indicated (R1) was unable to recall the fall and unable to recall what or how (R1) fell that day. Hospice records revealed (R1) did not sustain fractures due to the unwitnessed fall.

On 11/26/24 resident #1 (R1) was admitted to Torrance Memorial Hospital for general weakness and unresponsiveness according to an Unusual Incident Report LIC 624 (dated: 11/28/22). Medical records (dated: 04/23/23) indicated (R1) was admitted and treated for Septic Shock. (R1) did not sustain any fractures as a result of the unwitnessed fall, according to medical records.

On 03/01/24 between 09:50 am – 11:18 am, the Department interviewed administrator (A1) and (3) out (3) staff #1-#3. (A1-S1) stated they were both aware of an unwitnessed fall incident that occurred with (R1) and that immediate medical attention was provided. (A1-S1) stated that this was the only incident involving (R1) in the fall. (A1) and (S1-S3) claimed that (R1) did not have any witness or unwitnessed falls before 11/25/22. Facility progress notes (dated: 11/19/22 – 11/26/22), (R1) was being monitored hourly by staff. Physician’s Report (dated: 07/27/22) and Individualized Service Plan (dated: 08/10/22) did not order (R1) for 24/7 one-on-one supervision.

(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: 03/14/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/14/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 11-AS-20221128132320
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: 03/14/2024
NARRATIVE
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On 03/01/24 between 01:10 pm – 01:48 pm, the Department interviewed (8) out of (8) residents #2-#9 (R2-R9) reported not to have experienced or observed any resident sustained a fall due to lack of supervision or care. On 03/04/24 between 01:04 pm – 02:11 pm, the Department interviewed family representative witness #1 (W1) claimed the facility was well maintained and managed. (W1) felt that (R1’s) condition improved when (R1) transitioned back to this facility from recovering at the skilled nursing facility. (W1) stated that the fall on 11/25/22 was an isolated incident and it was not the main cause for (R1) to be hospitalized on 11/26/22. Medical and hospice records revealed (R1) did not suffer fractures due to the unwitnessed fall. Based on gathered information, there is no evidence to support the allegation is due to neglect/lack of care “Resident sustained a fall while in care”.

Allegation #2: Staff did not seek timely medical attention for a resident.

The details of this complaint alleged the facility failed to seek medical attention for resident #1 (R1). The complainant reported (R1) had a fall on 11/24/22 at the facility and did not receive medical attention until 11/26/22. There were no further details provided by the reporting party.

On 11/26/24 resident #1 (R1) was admitted to Torrance Memorial Hospital. Medical records (dated: 04/23/23) indicated (R1) was brought in and treated for Septic Shock. On 11/25/22 at 4:30 am, (R1) had an unwitnessed fall and was discovered by facility staff while doing routine rounds. (R1) was assisted by the staff who was found lying on the floor in (R1’s) room with an apparent head injury.

On 11/25/22 at 6:30 am Beacon Hospice Care registered nurse conducted a complete Neurological Examination with (R1). Hospice Medical Records indicated that (R1) was at baseline awake, responsive with a slight confusion. No motor dysfunction observed. No visible fracture and no bluish discoloration were noted. (R1) was able to move all extremities without discomfort. (R1) was unable to recall a recent fall and unable to recall what or how (R1) fell earlier that day. The hospice medical physician was notified of (R1’s) fall. The facility care staff was instructed to give (R1) morning medications and to assist with pain management and instructed to call hospice for any changes in condition.

(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: 03/14/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/14/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 5
Control Number 11-AS-20221128132320
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: 03/14/2024
NARRATIVE
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On 03/01/24 between 09:50 am – 11:18 am, the Department interviewed administrator (A1) and (3) out (3) staff #1-#3. (A1-S1) and stated they were both aware of a fall incident that occurred with (R1) and that immediate medical attention was provided. (S2-S3) does not recall a fall incident with (R1), however, stated that medical attention would be implemented by the facility immediately. (A1) claimed that (R1) was under hospice care with Beacon Care Hospice was notified and sent a registered nurse to examine (R1) on the same day of the fall. Beacon Hospice medical records (dated: 03/08/24) verified on 11/25/22 that medical attention was given to (R1). (A1) also reported a nurse practitioner came out to conduct a medical assessment later that day 11/25/22 from (R1’s) Scan Health Plan. A review of an Unusual Incident Report LIC 624 (dated: 11/28/22) verified (A1’s) statement that immediate medical attention was provided to (R1) on 11/25/22.

On 03/01/24 between 01:10 pm – 01:48 pm, the Department interviewed (8) out of (8) residents #2-#9 (R2-R9) and claimed that facility staff are responsive to provide prompt medical assistance. On 03/04/24 between 01:04 pm – 02:11 pm, the Department interviewed family representative witness #1 (W1) claimed to have been notified by staff of the fall and that medical attention was issued promptly. Based on the gathered information, there is no evidence to support the allegation due to neglect/lack of care “Staff did not seek timely medical attention for a resident.”.

Allegation #3: Resident developed multiple pressure injuries while in care.

The details of this complaint alleged that resident #1 (R1) sustained multiple skin ulcers while in care. It is reported by the complainant upon medical assessment, (R1) revealed to have various skin ulcers in one or two stages. The complainant did not provide further detailed information on this matter.



Resident #1 (R1) was admitted to Oakmont of Torrance on 08/11/2022. From 11/08/2022 – 11/19/2022 (R1) was at a skilled nursing facility Atlantic Memorial Long Beach. (R1) was readmitted at Oakmont of Torrance on 11/19/22 – 11/26/22 under hospice care with Beacon Hospice Inc. (R1) when admitted by Beacon Hospice with a wound care plan in place. The plan is to educate the caregiver to inspect the skin, especially bony prominences and dependent areas, for pallor, redness, and breakdown. Perform skin assessment and understand skin treatment and instructions.

(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: 03/14/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/14/2024
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 11-AS-20221128132320
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: 03/14/2024
NARRATIVE
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(R1) was medically examined on 11/19/22, 11/22/22, and 11/23/22 by a hospice nurse with no rash, wound/skin impairment, or pressure ulcers. (R1) was not prescribed with any medications to treat any skin conditions. However, on 11/25/22, (R1) was assessed with (top of head abrasion stage 1) due to the fall incident early morning on 11/25/22. The abrasion was treated with antibiotic ointment by hospice. (R1) was on blood thinning medications. It is noted blood thinner medication makes the skin and elasticity of the skin prominent for discolorations.

On 03/01/24 between 09:50 am – 11:18 am, the Department interviewed administrator (A1) and (3) out (3) staff #1-#3. (A1) and (S1-S3) all claimed that (R1) did not sustain multiple stage 1 or 2 injuries. (A1-S1) only recalled (R1) being observed with a minor head abrasion due to the unwitnessed fall on 11/25/22 that hospice had treated the same day. (A1) claimed that (R1) did not have any wounds, skin tears, or rashes before (R1’s) fall on 11/25/22. (S1-S2) claimed (R1) was monitored every two hours and that body assessments were done daily with residents.

On 03/01/24 between 01:10 pm – 01:48 pm, the Department interviewed (8) out of (8) residents #2-#9 (R2-R9) reported not to have any knowledge of any residents who sustained pressure injuries for staff lack of care. On 03/04/24 between 01:04 pm – 02:11 pm, the Department interviewed family representative witness #1 (W1) who is very much involved with (R1’s) care with routine visitations, stated that (R1) did not have any wounds, rashes, or ulcers before (R1’s) fall.

Medical Records from Torrance Memorial (dated: 04/24/23) only mentioned (R1) was assessed with ¼ inch laceration with abrasion and hematoma to the right parietal from the fall incident on 11/25/22. Based on the gathered information, there is no evidence to corroborate the allegation due to neglect/lack of care “Resident developed multiple pressure injuries while in care”.

Based on the information gathered, an inspection of the facility, observation, and interviews conducted, an analysis of records reviewed, the Department found no evidence to support the allegations mentioned above. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations, did or did not occur, therefore the allegations are Unsubstantiated.

An exit interview was conducted with Judi Uy-Villaruz, and copies of this report were issued.
SUPERVISOR'S NAME: Janae HammondTELEPHONE: (424) 544-1027
LICENSING EVALUATOR NAME: Ernand DabuetTELEPHONE: (323) 629-5526
LICENSING EVALUATOR SIGNATURE:

DATE: 03/14/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/14/2024
LIC9099 (FAS) - (06/04)
Page: 5 of 5