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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306006005
Report Date: 09/13/2022
Date Signed: 09/13/2022 11:47:03 AM


Document Has Been Signed on 09/13/2022 11:47 AM - 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, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868



FACILITY NAME:OAKMONT OF HUNTINGTON BEACHFACILITY NUMBER:
306006005
ADMINISTRATOR:ACOSTA-LOUER, SANDRAFACILITY TYPE:
740
ADDRESS:18922 DELAWARE STREETTELEPHONE:
(657) 204-4600
CITY:HUNTINGTON BEACHSTATE: CAZIP CODE:
92648
CAPACITY:111CENSUS: 75DATE:
09/13/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
09:12 AM
MET WITH:Executive Director Sandra Acosta-LouerTIME COMPLETED:
12:00 PM
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Licensing Program Analyst (LPA) Jenifer Tirre conducted this unannounced case management visit in order to follow up on an Self reported SOC 341 which was received by the department on 9/7/2022. The alleged incident happened on 9/7/22. LPA Tirre met with Executive Director Sandra Acosta-Louer and Memory Care Director Lynn Pabelona.
According to Executive Director (ED)Sandra Acosta-Louer Resident informed family that two caregivers spoke inappropriately to resident and kissed resident on arms and top of head. During this case management visit, LPA Tirre reviewed Resident's (R1) records. Resident's Physician's Report dated 11/9/2021 states R1 has a Primary diagnosis of Dementia. Report also indicates R1's mental condition is confused and disoriented along with inappropriate behavior at times. At time of incident Facility notified Licensing, Ombudsman and PCP. ED Acosta-Lauer states that at time of visit they called Huntington Beach Police and a officer came out to take R1's statement. ED Acosta-Louer provided police report information. ED also mentioned that facility is following up with caregivers doing re- training of personal rights and communication with Dementia residents. ED will follow up with LPA once staff training is complete.

LPA Tirre also met and talked with facility staff and Resident (R1). LPA Tirre obtained statements. During statement with R1, R1's daughter came in to visit and R1 did not recognize them. LPA observed R1 to be neatly groomed and room was neat in appearance. R1 resides in Memory care unit of facility.


An exit interview was conducted and a copy of this report along with a copy of LIC 811 was provided to Facility.
SUPERVISOR'S NAME: Alisa OrtizTELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Jenifer TirreTELEPHONE: (714) 703-2840
LICENSING EVALUATOR SIGNATURE:
DATE: 09/13/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/13/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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