198320250-1-29-2025-11-AS-EMAZ-DEYRV9-20250321132109

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198320250
Report Date: 01/29/2025
Date Signed: 01/29/2025 05:06:47 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
09/25/2024 and conducted by Evaluator Wendy Gibbs

COMPLAINT CONTROL NUMBER: 11-AS-20240925165205

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: 80	DATE:	01/29/2025
		UNANNOUNCED	TIME BEGAN:	03:36 PM
MET WITH:	Judith Uy-Villaruz		TIME COMPLETED:	05:00 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Staff did not adequately assist resident with repositioning.

INVESTIGATION FINDINGS:

1
2
3
4
5
6
7
8
9
10
11
12
13

On 01/29/25, the department conducted a subsequent unannounced compliant visit to deliver the findings. The department met with Administrator, Judith Uy and Health Services Director, Angel Pasa, and the purpose of today’s visit was explained.
On 10/31/24, the department conducted a subsequent unannounced complaint visit to the facility. During the visit, the department conducted a facility tour, interviewed Residents R1 and R7-R10, and received documents pertinent to the investigation. The following documents were received and reviewed current Home Health Agency Care Notes, and an updated resident reminders to assist with turning each shift.
During the initial visit conducted on 10/02/24 the department toured the facility, interviewed Staff (S1- S10), interviewed Residents (R2-R6), and received documents pertinent to the investigation. The following documents were received and reviewed: Staff roster, Resident Roster, Resident Information Form, resident Physician’s Report, Assessment Summary, Memory Care Assessment, resident Individualized Service Plan, resident reminder, Shower Skin Sheet, Home Health Agency Care Notes, email from Home Health Agency, Charting Notes, Resident Care Notes, and staff Training Log.
The investigation revealed the following:

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Wendy Gibbs
LICENSING EVALUATOR SIGNATURE:	DATE: 01/29/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/29/2025

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 4

Control Number 11-AS-20240925165205

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: 01/29/2025

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

Allegation: Staff did not adequately assist resident with repositioning.
The complaint allegation alleges that due to not being repositioned frequently resident has developed redness on the sacrum and a blister on their heel.
During record review the department received and reviewed R1’s Physician Report dated 07/26/24 that indicated the resident is nonambulatory. Additionally, the Physician’s Report indicated R1 requires Continuous Bed Care, requires assistance with Incontinence, and is unable to transfer independently.
Additionally, during record review the department received and reviewed R1’s physicians request for home health services dated 09/12/24. On the referral, the department observed, R1 was diagnosed with a “pressure ulcer of left heel stage 1.”
During the facility tour, the department observed a board in the Medication Room that indicated Alert Charting that had R1 listed for wounds on both heels. Additionally, the department observed a Reminder Schedule for all shifts to assist R1 with repositioning or transferring, and incontinence care every two (2) hours.
During record review, the department received and reviewed staff training logs from Relias for five (5) Staff. The department observed five (5) out of five (5), have had trainings including The skin and Pressure Injuries, Proper Positioning, and Recognizing and Reporting Skin Conditions.
During interviews with Staff S1-S10, were asked how often a resident who requires assistance with repositioning is assisted, ten (10) out of ten (10) stated they help residents reposition every 2 hours. Additionally, Staff S1-S10 were asked how frequently residents are checked for pressure injuries, ten (10) out of ten (10),

SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Wendy Gibbs
LICENSING EVALUATOR SIGNATURE:	DATE: 01/29/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/29/2025

LIC9099 (FAS) - (06/04)

Page: 2 of 4

Control Number 11-AS-20240925165205

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: 01/29/2025

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

stated residents are checked daily.
During interviews with Residents R2- R10, were asked if they have sustained pressure injuries while in care, nine (9) out of nine (9) stated they have not sustained pressure injuries while in care. Additionally, R7 and R8 stated staff assist them with repositioning on a regular basis.
During interviews with the Home Health Agency Nurse (W1), indicated on their visit on 09/25/2024, it was recommended to staff to reposition Resident R1 every 2 hours, apply ointment or lotion to the heels, and continue using cream the doctor ordered. During an interview with W1 on 10/03/2024, they indicated the bottom was looking better and the heels were worse. W1 recommended to elevate heels off the bed, apply lotion or ointment, cover the heels with band aids and put socks on when R1 is in the wheelchair and continue to reposition every 2-3 hours. Additionally, during an interview with W2 on 10/10/2024, indicated they showed care staff how the feet should be elevated to keep pressure off the heels, keep R1’s heels covered when in their chair and uncovered when in bed to dry out, and to continue to assist with repositioning every 2 hours.
During facility visits, the department observed R1 in their wheelchair. R1 had their heel covered with a bandage and socks on. Additionally, the department observed pillows and cushions on the wheelchair to help protect the heels.

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.

SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Wendy Gibbs
LICENSING EVALUATOR SIGNATURE:	DATE: 01/29/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/29/2025

LIC9099 (FAS) - (06/04)

Page: 3 of 4

Control Number 11-AS-20240925165205

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: 01/29/2025

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32	An exit interview was conducted with Executive Director, Judith Uy and a copy of the report was provided.

SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Wendy Gibbs
LICENSING EVALUATOR SIGNATURE:	DATE: 01/29/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/29/2025

LIC9099 (FAS) - (06/04)

Page: 4 of 4