198602583-6-10-2021-28-AS-MVAO-C4ANB8-20210624101842

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198602583
Report Date: 06/09/2021
Date Signed: 06/10/2021 09:41:42 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
02/07/2020 and conducted by Evaluator Glenn Trueman

COMPLAINT CONTROL NUMBER: 28-AS-20200207142412

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: 37	DATE:	06/09/2021
		UNANNOUNCED	TIME BEGAN:	09:45 AM
MET WITH:	Administrator Donell Clark		TIME COMPLETED:	12:45 PM

ALLEGATION(S):

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Staff failed to administer resident medications resulting in hospitalization
Staff failed to seek resident timely medical emergency services

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Glenn Trueman made an unannounced visit to the facility and was greeted by Administrator Donell Clark and explained the reason for the visit.
The purpose of the visit is a subsequent visit for initial complaint dated 2/07/2020.
At today's visit 6/09/2021 at 9:45 AM Staff Jennifer Liefveld was interviewed.
At 10:00 AM to 12:00 PM Resident's 1-6 were interviewed.
Resident and Staff Rosters were submitted.
In regards to the allegation Staff failed to administer resident medications resulting in hospitalization, all 6 resident's interviewed today 06/09/2021 stated that medication is administered 3x a day and there has never been a problem. Staff have never missed a dose and act professionally. Staff will come to their room or administer in the dining room. Regarding Resident # 7 the following was observed:
On 1/22/2022 Eliquis 5 mg ordered
On 1/20/2020 discharge orders to discontinue (dc) Xarelto.
On 1/17/2020 Medication Lasix 40 mg ordered per physician.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Wei Siew Ho	TELEPHONE: (323) 981-3969
LICENSING EVALUATOR NAME: Glenn Trueman	TELEPHONE: (323) 981-1652
LICENSING EVALUATOR SIGNATURE:	DATE: 06/09/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/09/2021

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-20200207142412

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: 06/09/2021

NARRATIVE

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On 12/12 2019 discharge med list with new orders for Lorezapam and discontinue(dc) metoprolol cranberry, furosemide and hydrocortisone.
Mar's Log confirms Eliquis and lasix administered per staff initials and Xarelto discontinued.
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.

In regards to the allegation Staff failed to seek resident timely medical emergency services, all 6 resident's interviewed stated that staff will act immediately if a physican is needed and if an ambulance is needed.
Interviews conducted revealed that facility would send resident to ER for medical attention when needed and call 911 if prompt medical attention is needed.
Internal facility notes show that 911 was called 12/5/2019 and Resident # 7 said she was fine and paramedics were angry and said it was an abuse of the system.
Resident # 7 at nite continued with normal routine at facility with temperature at 99.2 at 11:30 PM.

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 conducted.

SUPERVISOR'S NAME: Wei Siew Ho	TELEPHONE: (323) 981-3969
LICENSING EVALUATOR NAME: Glenn Trueman	TELEPHONE: (323) 981-1652
LICENSING EVALUATOR SIGNATURE:	DATE: 06/09/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/09/2021

LIC9099 (FAS) - (06/04)

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