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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198602583
Report Date: 03/23/2021
Date Signed: 03/23/2021 04:00:03 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 Glenn Trueman
PUBLIC
COMPLAINT CONTROL NUMBER: 28-AS-20191126122617
FACILITY NAME:OAK PARK MANOR, LPFACILITY NUMBER:
198602583
ADMINISTRATOR:JOHNSON, SABRINAFACILITY TYPE:
740
ADDRESS:501 S COLLEGE AVENUETELEPHONE:
(909) 626-0117
CITY:CLAREMONTSTATE: CAZIP CODE:
91711
CAPACITY:68CENSUS: 39DATE:
03/23/2021
UNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Assistant Administrator Donell ClarkTIME COMPLETED:
04:00 PM
ALLEGATION(S):
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9
Facility allowed a nurse practitioner to complete a Physician's Report
Facility failed to provide updated Personal Rights list with Admissions Agreement
Facility failed to complete a Needs and Services Plan for resident
Facility failed to obtain physician's order for resident's postural support
Facility not following approved plan of operation
Facility administered medications without physician's orders
INVESTIGATION FINDINGS:
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 The purpose of the report today is to deliver the findings from the original complaint dated 11/26/2019. On initial visit 12/2/2019 Licensing Program Analyst (LPA) Glenn Trueman made an unannounced visit to the facility and was greeted by Administrator Sabrina Johnson and explained the reason for the visit.
At 9:30 AM file for Resident 1 was reviewed. At 10:15 AM Staff 1 was interviewed. At 10:50 AM Administrator Sabrina Johnson was interviewed. At 11:35 Staff 2 was interviewed.
In regards to the allegation Facility allowed a nurse practitioner to complete a Physician's Report, Administrator confirmed during interview conducted on 12/2/2019 that the Nurse Practitioner signed and it was suppose to be the Primary Physician. Physician's Report also shows the signature of the Nurse Practitioner. Based on LPAs interviews conducted and records reviewed, the preponderance of evidence
standard has been met, therefore the above allegations are SUBSTANTIATED.
In regards to the allegation Facility failed to provide updated Personal Rights list with Admissions Agreement, Administrator confirmed that they did not have the updated one and review of the documents and file there was not the updated Personal Rights list.


Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Rebecca OrendainTELEPHONE: (323) 981-3969
LICENSING EVALUATOR NAME: Glenn TruemanTELEPHONE: (323) 981-1652
LICENSING EVALUATOR SIGNATURE:

DATE: 03/23/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/23/2021
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 6
Control Number 28-AS-20191126122617
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: 03/23/2021
NARRATIVE
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Based on LPAs interviews conducted and records reviewed, the preponderance of evidence standard has been met, therefore the above allegations are SUBSTANTIATED.
In regards to the allegation that the Facility failed to complete a Needs and Services Plan for resident, Administrator confirmed that Resident 1 was there only 1 day so they didn't get to do it.
Based on LPAs interviews conducted and records reviewed, the preponderance of evidence standard has been met, therefore the above allegations are SUBSTANTIATED.
In regards to the allegation Facility failed to obtain physician's order for resident's postural support, Administrator confirmed that Resident 1 upon entering facility had a knee brace, but confirmed that facility did not obtain a Physician[s Order for it.
Based on LPAs interviews conducted and records reviewed, the preponderance of evidence standard has been met, therefore the above allegations are SUBSTANTIATED.
In regards to the allegation Facility not following approved plan of operation, based on interviews conducted and information gathered facility did not get timely medical attention. Resident 1 had fallen and was in pain, but 911 was not called until 9 hours later.
Based on LPAs interviews conducted and records reviewed, the preponderance of evidence standard has been met, therefore the above allegations are SUBSTANTIATED.
In regards to the allegation Facility administered medications without physician's orders, Wellness Director confirmed that they had faxed to the doctor for the prescription, but had not gotten it back from the doctor.
Facility was still administering medication from bottle provided upon admission, but did not obtain physician's order.
Based on LPAs interviews conducted and records reviewed, the preponderance of evidence standard has been met, therefore the above allegations are SUBSTANTIATED.


.
SUPERVISOR'S NAME: Rebecca OrendainTELEPHONE: (323) 981-3969
LICENSING EVALUATOR NAME: Glenn TruemanTELEPHONE: (323) 981-1652
LICENSING EVALUATOR SIGNATURE:

DATE: 03/23/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/23/2021
LIC9099 (FAS) - (06/04)
Page: 2 of 6
Control Number 28-AS-20191126122617
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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/23/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
03/30/2021
Section Cited
CCR
87458(a)
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7
Medical Assessment
Prior to a person's acceptance as a resident, the licensee shall obtain and keep on file, documentation of a medical assessment, signed by a physician, made within the last year.
This requirement is not met as evidenced by:
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Facility to Review Regulation 87458(a) and self certify that medical assessment will be signed by a physicain by POC due date.
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Based on record review licensee failed to have a medical assessment signed by a physician with only the Nurse Practitioner signing which posed a potential Health, Safety or Personal Rights risk to residents in care.
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Type B
03/30/2021
Section Cited
CCR
87468(b)(1)
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7
Personal Rights
At the time the admission agreement is signed, a resident and the resident's representative shall be personally advised of and given a copy of:
(1) The personal rights of residents specified in Sections 87468.1, Personal Rights of Residents in All Facilities or and 87468.2, Additional Personal Rights of
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Residents in Privately Operated Facilities, as applicable to the facility.
This requirement is not met as evidenced by:
Licensee failed to provide updated Personal Rights list with Admissions Agreement which posed a potential Health, Safety or Personal Rights risk to residents in care.
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Facility to submit an updated Personal rights list by POC due date.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Rebecca OrendainTELEPHONE: (323) 981-3969
LICENSING EVALUATOR NAME: Glenn TruemanTELEPHONE: (323) 981-1652
LICENSING EVALUATOR SIGNATURE:

DATE: 03/23/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/23/2021
LIC9099 (FAS) - (06/04)
Page: 3 of 6
Control Number 28-AS-20191126122617
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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/23/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
03/30/2021
Section Cited
CCR
87463(a)
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7
The pre-admission appraisal shall be updated, in writing as frequently as necessary to note significant changes and to keep the appraisal accurate. The reappraisals shall document changes in the resident's physical, medical, mental, and social condition
This requirement is not met as evidenced by:
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Facility to submit Needs and Services Plan by POC due date.
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Based on record review the licensee failed to complete a Needs and Services Plan which posed a potential Health, Safety or Personal Rights risk to residents in care.
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Type B
03/30/2021
Section Cited
CCR
87608(a)(3)
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Postural Supports
A written order from a physician indicating the need for the postural support shall be maintained in the resident’s record. The licensing agency shall be authorized to require other additional documentation if needed to verify the order. This requirement is not met as evidenced by
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Facility to submit physician's order for postural support by POC due date.
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Based on record review the licensee failed to have a written order indicating the need for a postural support for residents in care.
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14
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Rebecca OrendainTELEPHONE: (323) 981-3969
LICENSING EVALUATOR NAME: Glenn TruemanTELEPHONE: (323) 981-1652
LICENSING EVALUATOR SIGNATURE:

DATE: 03/23/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/23/2021
LIC9099 (FAS) - (06/04)
Page: 4 of 6
Control Number 28-AS-20191126122617
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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/23/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
03/30/2021
Section Cited
CCR
87208(a)
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2
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6
7
Plan of Operation
Each facility shall have and maintain a current, written definitive plan of operation. The plan and related materials shall be on file in the facility and shall be submitted to the licensing agency with the license application. Any significant changes in the plan of operation which would affect the services to residents shall be submitted to the licensing agency for approval.
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Facility to review Regulation 87208 and submit self certification by POC due date that facility will follow plan of operation.
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This requirement is not met as evidenced by:
Based on interviews conducted licensee failed to follow plan of operation by failing to get medical attention in a timely manner which posed a potential Health, Safety or Personal Rights risk to residents in care.
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9
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14
Type B
03/30/2021
Section Cited
CCR
87465(2)
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Incidental Medical and Dental
Once ordered by the physician the medication is given according to the physician's directions.
This requirement is not met as evidenced by:
Based on interviews conducted medication was administered to Resident 1 without obtaining a Physician's Order which posed
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Facility to review Section 87465 and submit self certification by POC due date that facility will follow medication procedures.
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a potential Health, Safety or Personal Rights risk to residents in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Rebecca OrendainTELEPHONE: (323) 981-3969
LICENSING EVALUATOR NAME: Glenn TruemanTELEPHONE: (323) 981-1652
LICENSING EVALUATOR SIGNATURE:

DATE: 03/23/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/23/2021
LIC9099 (FAS) - (06/04)
Page: 5 of 6
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 Glenn Trueman
PUBLIC
COMPLAINT CONTROL NUMBER: 28-AS-20191126122617

FACILITY NAME:OAK PARK MANOR, LPFACILITY NUMBER:
198602583
ADMINISTRATOR:JOHNSON, SABRINAFACILITY TYPE:
740
ADDRESS:501 S COLLEGE AVENUETELEPHONE:
(909) 626-0117
CITY:CLAREMONTSTATE: CAZIP CODE:
91711
CAPACITY:68CENSUS: 39DATE:
03/23/2021
UNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Donell ClarkTIME COMPLETED:
04:00 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Facility submitted false information on incident report
Facility not accurately documenting medication administration
INVESTIGATION FINDINGS:
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In regards to the allegation Facility submitted false information on incident report based on interviews conducted and information gathered that written on the incident report is stating the hour occurring at 10 instead of 9. Wellness Director acknowledged this was a mistake and not purposely falsifying information.
Upon review of the report all the details are consistent with the events that occurred and the only discrepancy was the hour stated.

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.

In regards to the allegation Facility not accurately documenting medication administration, based on record review the documentation was consistent and accurate regarding medication administered.
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.


Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Rebecca OrendainTELEPHONE: (323) 981-3969
LICENSING EVALUATOR NAME: Glenn TruemanTELEPHONE: (323) 981-1652
LICENSING EVALUATOR SIGNATURE:

DATE: 03/23/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/23/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 6 of 6