198602583-5-25-2022-28-AS-SCOL-CERTJW-20220525144700

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198602583
Report Date: 10/27/2021
Date Signed: 05/25/2022 11:00:14 AM

Unsubstantiated

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
08/19/2020 and conducted by Evaluator Linda M Almaraz

COMPLAINT CONTROL NUMBER: 28-AS-20200819152754

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:	0	CENSUS: 0	DATE:	10/27/2021
		UNANNOUNCED	TIME BEGAN:	11:31 AM
MET WITH:			TIME COMPLETED:	12:45 PM

ALLEGATION(S):

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Facility could not provide the level of care required for the resident

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Linda Almaraz conducted a subsequent complaint visit to investigate the allegation listed above. LPA met with Administrator Donell Clark and explained the reason for todays visit.

The investigation consisted of the following: On 8/25/2020, LPA Almaraz interviewed former Administrator Jennifer Serrano and Staff #1-6. LPA also requested and received a staff roster, resident roster, incident reports/medical records and Resident #1-4 files. On 10/22/2021, LPA's Jewel Baptiste and Almaraz interviewed Residents #1-4, and obtain additional records. On 10/27/2021, LPA Almaraz requested additional documents for Resident #1.

The investigation revealed the following: Resident #1 was admitted to Oak Park Manor, LP on 11/04/2018. Records show the resident was part of the Assisted Living Waiver (ALW) Program and had a Individual Service Plan (ISP) completed prior to being admitted to the facility. (Continued on an LIC 9099C)

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Stefanie Coronel	TELEPHONE: (323) 981-3978
LICENSING EVALUATOR NAME: Alberto Lopez	TELEPHONE: (323) 981-3307
LICENSING EVALUATOR SIGNATURE:	DATE: 10/27/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/27/2021

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-20200819152754

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: 10/27/2021

NARRATIVE

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The ISP dated 10/18/2018 stated the resident had a history of aggression towards caregivers in previous RCFE's and had prior incidences of striking out at staff. Immediately after, as day went by the resident started to show aggression towards staff and others. Records indicate the facility contacted the Doctor and had him re-evaluated and medication was adjusted. Records revealed the facility had multiple contacts with the Doctor. The facility conducted a re-appraisal on 04/17/2019 and the facility continued to work with the resident. On 9/9/2019, the Doctor determined the resident needed higher Psychiatric level of care that the facility could not provide.

Based on LPA's interviews conducted, and records reviewed, investigation revealed: Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the above allegation is unsubstantiated.

No Deficiencies cited under California Code of Regulations Title 22. An exit Interview was conducted with the Administrator and a hardcopy was provided.

SUPERVISOR'S NAME: Christine Yee	TELEPHONE: (323) 981-3978
LICENSING EVALUATOR NAME: Linda M Almaraz	TELEPHONE: (323) 981-3307
LICENSING EVALUATOR SIGNATURE:	DATE: 10/27/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/27/2021

LIC9099 (FAS) - (06/04)

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