306005673-4-6-2021-22-AS-AORZ-C23RY4-20210414132541

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 306005673
Report Date: 04/06/2021
Date Signed: 04/06/2021 01:18:16 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

This is an official report of an unannounced visit/investigation of a complaint received in our office on
10/12/2020 and conducted by Evaluator Kimberly Lyman

COMPLAINT CONTROL NUMBER: 22-AS-20201012081437

FACILITY NAME:	OAKMONT OF HUNTINGTON BEACH		FACILITY NUMBER:	306005673
ADMINISTRATOR:	AYALA, ROSA		FACILITY TYPE:	740
ADDRESS:	18922 DELAWARE STREET		TELEPHONE:	(657) 204-4600
CITY:	HUNTINGTON	STATE: CA	ZIP CODE:	92648
CAPACITY:	111	CENSUS: 71	DATE:	04/06/2021
		UNANNOUNCED	TIME BEGAN:	01:07 PM
MET WITH:	Rosa Ayala		TIME COMPLETED:	01:25 PM

ALLEGATION(S):

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Staff did not ensure facility was free from pests

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Kimberly Lyman contacted the facility via telephone to deliver findings on a complaint investigation via telephone due to COVID-19 and pre-cautionary measures. LPA identified herself and discussed the purpose of the call and elements of allegatios with Administrator Rosa Ayala.

During the course of the investigation, LPA toured the facility, reviewed and obtained pertinent documentation such as Eco-Lab extermination records as well as interviewed facility Administrator and staff. Regarding the allegation that staff did not ensure facility was free from pests, the investigation revealed the following: On 09/12/2020, facility staff reported seeing possible bed bugs on the wall in room 117. Both occupants of the room were relocated as well as occupant of room 118. All resident families were notified and skin checks performed. No evidence of redness or itching present on body checks. Facility provided documentation from Eco-lab for extermination services provided from 09/12/2020-10/12/2020. Eco-Lab inspected rooms 100-118 and documentation indicates bed bugs noted in rooms 117 and 118 as well as in the smoke detector and vents. Eco-Lab serviced noted areas. Three out of three caregivers CONTINUED ON LIC 9099C DATED 04/06/2021

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Alisa Ortiz	TELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Kimberly Lyman	TELEPHONE: (714) 795-1497
LICENSING EVALUATOR SIGNATURE:	DATE: 04/06/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/06/2021

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 22-AS-20201012081437

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: OAKMONT OF HUNTINGTON BEACH	FACILITY NUMBER: 306005673
	VISIT DATE: 04/06/2021

NARRATIVE

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interviewed in the memory care unit indicate facility responded immediately to concerns of bed bugs. All staff interviewed stated bed/ bedding was replaced. Therefore the allegation is deemed unsubstantiated, meaning that although the allegation may have happened or are valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. An exit interview was conducted with Administrator Rosa Ayala via telephone and a copy of this report was provided to Administrator via email and an electronic email read receipt confirms receiving these documents.

*This is an amended report to include closing verbiage/ exit interview.

SUPERVISOR'S NAME: Alisa Ortiz	TELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Kimberly Lyman	TELEPHONE: (714) 795-1497
LICENSING EVALUATOR SIGNATURE:	DATE: 04/06/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/06/2021

LIC9099 (FAS) - (06/04)

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