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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198602583
Report Date: 10/27/2022
Date Signed: 10/27/2022 02:58:23 PM


Document Has Been Signed on 10/27/2022 02:58 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		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, LPFACILITY NUMBER:
198602583
ADMINISTRATOR:JOHNSON, SABRINAFACILITY TYPE:
740
ADDRESS:501 S COLLEGE AVENUETELEPHONE:
(909) 626-0117
CITY:CLAREMONTSTATE: CAZIP CODE:
91711
CAPACITY:0CENSUS: 0DATE:
10/27/2022
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
02:15 PM
MET WITH:Verity CardaTIME COMPLETED:
03:30 PM
NARRATIVE
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Licensing Program Analyst (LPA) Christine Wong made an unannounced case management visit to cite for deficiencies related to complaint investigation control #28-AS-20201229154337. LPA met with LVN Verity Carda and discussed the purpose of the visit.

On 01/06/2021, LPA conducted the initial complaint visit via teleconference and interviewed Jennifer Liefveld, Administrator and Staff#1 (S1). LPA Wong also obtained copies of documents pertaining to resident#1 (R1) including: R1's Identification and Emergency Information/Face sheet, recent physician report, appraisal/re-appraisal report, needs and service plan, medication list, recent doctor's order and/or the most recent medical documents, nursing notes, and residents roster and staff roster with contact information. LPA also obtained and reviewed hospital records and all attending doctor’s notes. A Department nurse consultant was also utilized during the investigation to review the medical records that were collected.

During the complaint investigation and based on documents reviewed, the facility staff reported that R1 had one episode of emesis on 12/15/20, however no documentation obtained indicated that facility notified R1’s family or responsible party of this incident. In addition, R1 had been complaining of leg pain and had one episode of emesis and facility staff did not bring this to the attention of R1’s physician and/or their responsible party.

Per Title 22, Division, 6, Chapter 8 has been cited. See LIC 809D.



Exit interview was held with LVN Verity Carda. A copy of this report and appeal rights were provided.
SUPERVISOR'S NAME: Christine YeeTELEPHONE: (323) 981-3978
LICENSING EVALUATOR NAME: Christine WongTELEPHONE: (323) 981-3963
LICENSING EVALUATOR SIGNATURE:
DATE: 10/27/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/27/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2


Document Has Been Signed on 10/27/2022 02:58 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 10/27/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
11/10/2022
Section Cited

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87466 Observation of the Resident. The licensee shall ensure that residents are regularly observed for changes in physical, mental, emotional and social functioning.... and brought to the attention of the resident's physician and the resident's responsible person, if any.
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The requirement was not met as evidenced by documents reviewed and interviews conducted. There's no documentation obtained indicated that facility notified R1’s family or responsible party of this incident which posed a potenital risk to residents in care
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Type B
11/10/2022
Section Cited

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87705 Care of Persons with Dementia (b) In addition to the requirements as specified in Section 87208, Plan of Operation, the plan of operation shall address the needs of residents with dementia, including: (1) Procedures for notifying the resident’s physician, family members and responsible persons who have requested notification, and conservator, if any, when a resident’s behavior or condition changes.
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The requirement was not met as evidenced by documents reviewed. R1 complained leg pain and one episode of emesis and staff did not bring the attention to physician or responsible party which posed an potential risk to residents care 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: Christine YeeTELEPHONE: (323) 981-3978
LICENSING EVALUATOR NAME: Christine WongTELEPHONE: (323) 981-3963
LICENSING EVALUATOR SIGNATURE:
DATE: 10/27/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/27/2022
LIC809 (FAS) - (06/04)
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