198602583-3-15-2022-28-AS-MVAO-CKZTSV-20221109135947

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198602583
Report Date: 03/15/2022
Date Signed: 03/15/2022 04:27:39 PM

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
12/29/2020 and conducted by Evaluator Christine Wong

PUBLIC

COMPLAINT CONTROL NUMBER: 28-AS-20201229154337

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: 55	DATE:	03/15/2022
		UNANNOUNCED	TIME BEGAN:	03:30 PM
MET WITH:	Donell Clark-Administrator		TIME COMPLETED:	04:45 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Facility failed to seek timely medical treatment for resident.
Facility failed to observe changes in resident’s health.
Staff did not assist resident with ADLs.

INVESTIGATION FINDINGS:

1
2
3
4
5
6
7
8
9
10
11
12
13

Licensing Program Analyst (LPA) Christine Wong conducted a subsequent complaint visit to deliver the findings of the investigation. LPA met with Receptionist-Tasha Stills and explained the reason of the visit. Shortly after, the administrator Donell Clark arrived.

The investigation consisted of the following: On 01/06/2021, LPA conducted the initial 10 days complaint 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 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 collected.
(See LIC 9099C for continuation)

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Christine Yee	TELEPHONE: (323) 981-3978
LICENSING EVALUATOR NAME: Christine Wong	TELEPHONE: (323) 981-3963
LICENSING EVALUATOR SIGNATURE:	DATE: 03/15/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/15/2022

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 2

Control Number 28-AS-20201229154337

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: 03/15/2022

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

The investigation revealed the following: Allegation#1 “Facility failed to seek timely medical treatment for resident.” The medical records obtained, revealed that when the facility found out that R1 had increased respirations and the oxygen saturation read 55%, the facility immediately called 911 and the resident was transported to the hospital and there was no delay in obtaining medical treatment. Days prior to R1 being admitted to the hospital, R1 had one episode of coughing or emesis. The facility staff continued to offer liquid and dinner for R1 even when R1 had very little intake of food or drink. Staff did not observe R1 with any fever or high temperature or any respiratory symptoms. The facility is not a medical facility and due to the lack of symptoms, the staff would not know if the resident required medical attention. In addition, R1 was taking the medication “Lasix” for treating the symptoms of fluid retention prior to being admitted to the hospital. The medication may have contributed to R1 being dehydrated.

Allegation#2 “Facility failed to observe changes in residents’ health” Before R1 was admitted to the hospital, the facility staff would check resident’s vital daily and ensure resident did not have any respiratory symptoms or fever. Although resident had an episode of coughing, emesis and leg pain, facility continued to monitor R1’s condition daily and administered pain medication for R1’s leg pain. The episode of coughing and emesis only lasted for a day.

Allegation#3 “Staff did not assist resident with ADLs.” LPA interviewed residents and all reported that staff assists them with their activities of daily living (ADL) and they are doing a good job. Staff stay on top of each residents’ ADLs. LPA also interviewed staff and they all denied the allegation and stated that R1 communicated her needs well with the staff. R1 was capable of feeding herself easily and staff assisted with dressing, grooming, toileting, bathing and walking.

Based on the record reviewed, 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 allegations are UNSUBSTANTIATED.

Exit interview, a copy of this report and Appeals Rights were provided to Administrator.

SUPERVISOR'S NAME: Christine Yee	TELEPHONE: (323) 981-3978
LICENSING EVALUATOR NAME: Christine Wong	TELEPHONE: (323) 981-3963
LICENSING EVALUATOR SIGNATURE:	DATE: 03/15/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/15/2022

LIC9099 (FAS) - (06/04)

Page: 2 of 2