198602583-1-22-2021-28-AS-MVAO-BXNPVH-20210127103911

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198602583
Report Date: 01/22/2021
Date Signed: 01/22/2021 01:50:17 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

This is an official report of an unannounced visit/investigation of a complaint received in our office on
11/26/2019 and conducted by Evaluator Tony Vasallo

PUBLIC

COMPLAINT CONTROL NUMBER: 28-AS-20191126123833

FACILITY NAME:	OAK PARK MANOR, LP		FACILITY NUMBER:	198602583
ADMINISTRATOR:	JOHNSON, SABRINA		FACILITY TYPE:	740
ADDRESS:	501 S COLLEGE AVENUE		TELEPHONE:	(909) 626-0117
CITY:	CLAREMONT	STATE: CA	ZIP CODE:	91711
CAPACITY:	68	CENSUS: 25	DATE:	01/22/2021
		UNANNOUNCED	TIME BEGAN:	01:30 PM
MET WITH:	Jennifer Liefveld, Administrator		TIME COMPLETED:	01:50 PM

ALLEGATION(S):

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Facility failed to report resident's change of condition to appropriate parties.
Facility failed to provide proper incontinence care.
Facility not following proper medication destruction procedures.
Facility insufficiently staffed to meet resident's needs.
Facility failed to complete a pre-admission appraisal prior to admission.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Vasallo initiated a subsequent complaint investigation for the allegations listed above. Due to the situation surrounding the Coronavirus Disease 2019 (COVID-19), and to implement mitigation measures, today’s subsequent complaint investigation was conducted telephonically with Jennifer Liefvel, administrator.

The investigation consisted of the following: The initial complaint visit was conducted on 12/2/19. During the initial visit interviews were conducted with 3 staff members. On 1/22/21, an additional telephone interview was conducted with a former staff member. LPA also reviewed Resident #1’s (R1) file including Medication Administration Record (MAR), preplacement appraisal, nurses notes, and responsible party’s contact information. LPA also reviewed facility’s staff schedule for December 2018, incident report involving R1, and facility call logs.

Continued on 9099C

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Wei Siew Ho	TELEPHONE: (323) 981-3969
LICENSING EVALUATOR NAME: Tony Vasallo	TELEPHONE: (323) 981-3977
LICENSING EVALUATOR SIGNATURE:	DATE: 01/22/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/22/2021

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 28-AS-20191126123833

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: OAK PARK MANOR, LP	FACILITY NUMBER: 198602583
	VISIT DATE: 01/22/2021

NARRATIVE

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The investigation revealed the following: Allegation: Facility failed to report resident's change of condition to appropriate parties. Nurses notes dated 12/28/18 at 9 pm indicate R1 fell on her buttocks and assessment was done. Notes indicate all parties were notified and incident report done. R1’s file was reviewed and responsible party's phone number was found. Facility provided call logs and it was determined R1’s responsible party was called on 12/28/18 at 8:59 pm and on 12/29/18 at 8:18 am. Facility also completed an incident report dated 12/31/18. Incident report documents R1’s fall and indicates R1’s responsible party was notified. The previous administrator was interviewed and she also indicated that staff notified her of the fall. Based on the information obtained the allegation is unsubstantiated.

Allegation: Facility failed to provide proper incontinence care. It’s alleged R1 did not receive incontinent care the night of 12/28/18 through the morning of 12/29/18. Allegedly R1 was in pain from the fall that occurred the night of 12/28/18 and staff did not want to move R1 or assist with incontinence care. 3 staff were interviewed on 12/2/19 and indicated they didn’t know if proper incontinence care was provided since R1 was only at the facility for 1 day. 1 former staff was contacted on 1/22/21 and interviewed over the phone. The staff member indicated they didn’t remember R1 and didn’t know if incontinence care was provided. Another former staff member was called, and the phone number is disconnected. There is insufficient evidence to prove this allegation.

Allegation: Facility not following proper medication destruction procedures. It’s alleged facility destroyed R1’s Norco medication. However, facility found the Norco medication after R1 moved out of the facility. There is an email sent to the responsible party's attorney dated 12/4/19 notifying them that the medication was found. Therefore, the allegation is unsubstantiated.

Allegation: Facility insufficiently staffed to meet resident's needs: The staff schedule was reviewed for December 2018. The schedule shows 3 caregivers and 1 LVN worked the night of 12/28/18 when R1 fell at the facility. The previous administrator confirmed those staff members worked on 12/28/18. 1 of the staff members was contacted on 1/22/21 and confirmed he/she worked that day, but did not have any other details and hasn’t worked for the facility in over a year. None of the other staff that worked the night of 12/28/18 work for the facility anymore and there is no updated contact information for them. There is insufficient evidence to prove this allegation.

Continued on 9099C.

SUPERVISOR'S NAME: Wei Siew Ho	TELEPHONE: (323) 981-3969
LICENSING EVALUATOR NAME: Tony Vasallo	TELEPHONE: (323) 981-3977
LICENSING EVALUATOR SIGNATURE:	DATE: 01/22/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/22/2021

LIC9099 (FAS) - (06/04)

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Control Number 28-AS-20191126123833

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: OAK PARK MANOR, LP	FACILITY NUMBER: 198602583
	VISIT DATE: 01/22/2021

NARRATIVE

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Allegation: Facility failed to complete a pre-admission appraisal prior to admission. R1’s record was reviewed. A preplacement appraisal dated 12/24/18 is in R1’s record. R1 was admitted on 12/28/18 and was discharged on 12/29/18. The appraisal documents R1’s needs and indicates R1’s family was interviewed. Based on the information obtained the allegation is unsubstantiated.

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.

A telephonic exit interview was conducted with Jennifer Liefvel, and a hard copy was provided via email for signature.

SUPERVISOR'S NAME: Wei Siew Ho	TELEPHONE: (323) 981-3969
LICENSING EVALUATOR NAME: Tony Vasallo	TELEPHONE: (323) 981-3977
LICENSING EVALUATOR SIGNATURE:	DATE: 01/22/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/22/2021

LIC9099 (FAS) - (06/04)

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