198602583-10-21-2020-28-AS-MVAO-BXUR9W-20210202115012

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198602583
Report Date: 10/20/2020
Date Signed: 10/21/2020 09:59:52 AM

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
10/13/2020 and conducted by Evaluator Linda M Almaraz

PUBLIC

COMPLAINT CONTROL NUMBER: 28-AS-20201013122308

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: 46	DATE:	10/20/2020
		UNANNOUNCED	TIME BEGAN:	10:45 AM
MET WITH:	Administrator, Jennifer Liefveld		TIME COMPLETED:	05:00 PM

ALLEGATION(S):

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Facility staff did not seek medical attention for resident in care

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Linda Almaraz initiated a complaint investigation for the allegations listed above. Due to the situation surrounding the Coronavirus Disease 2019 (COVID-19), and to implement mitigation measures, this complaint investigation was conducted telephonically with Administrator Jennifer Liefveld.

The investigation consisted of the following: LPA Almaraz interviewed the Administrator, Staff #1-4, former Staff #5-6, Residents #1-2 and attempted to interview Residents #3-4 but was unsuccesul (unable to interview due to Dementia). LPA also attempted to interview Resident #5 but the resident was asleep. LPA requested and received a staff roster, resident roster, and files for Residents #1-5.

**Refer to LIC 9099C for the continuation of this report***

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Christine Yee	TELEPHONE: (323) 981-3978
LICENSING EVALUATOR NAME: Linda M Almaraz	TELEPHONE: (323) 981-3307
LICENSING EVALUATOR SIGNATURE:	DATE: 10/20/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/20/2020

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-20201013122308

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: 10/20/2020

NARRATIVE

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The investigation revealed the following: Based on staff interviews, residents are checked daily every 2-3 hours and are required to do body checks on residents. Interviews revealed there is a documenting protocol that is done after showers. Staff are required to assess the residents and document any changes or findings, which is filed with the residents records. All staff interviewed and records indicated they immediately notify the Nurse or Med-Tech on duty of any findings or changes to the residents. Per staff, they have never had any of their reporting be neglected or not addressed. During the investigation it was revealed Resident #2 had a nevus that had changed in color and a rash. LPA was informed Resident #2 receives limited assistance while bathing and has only a caregiver waiting outside of the door because Resident #2 does not liked to be bath by caregivers. Resident #2 notified daughter of the rash and nevus during a visit. Per investigation, the facility was made aware by Residents' #2 daughter on 10/12/20 and the facility contacted the facility Medical Doctor on 10/12/20. The Doctor ordered blood work for the resident which was conducted on 10/17/20. Based on records reviewed, residents are assessed daily and are given their medication based on their doctor orders. Resident #2 received a new doctor order on 10/19/20. The facility has a Medical Doctor who goes to the facility twice a month and a physician assistant who goes once a week to check on residents with any issues or concerns the facility is aware of. The investigation reveal the facility was unable to provide medical attention to the rash and nevus because the resident did not notify the staff or allows the caregivers to help with bathing, therefore, unable to assess skin that is under Resident #2's clothing. Upon the facility being notified they contacted the doctor and provided medical attention. LPA did not find evidence that the facility staff did not seek medical attention for resident in care.

Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED.

Exit interview, a copy of this report (sent electronically for signature) and Appeals Rights were provided to Administrator.

SUPERVISOR'S NAME: Christine Yee	TELEPHONE: (323) 981-3978
LICENSING EVALUATOR NAME: Linda M Almaraz	TELEPHONE: (323) 981-3307
LICENSING EVALUATOR SIGNATURE:	DATE: 10/20/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/20/2020

LIC9099 (FAS) - (06/04)

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