366426338-11-4-2022-18-AS-EMAN-CLNQ5U-20221130105231

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 366426338
Report Date: 11/04/2022
Date Signed: 11/04/2022 12:28:39 PM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BERNARDINO, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

This is an official report of an unannounced visit/investigation of a complaint received in our office on
01/12/2021 and conducted by Evaluator Natalie Ibarra

PUBLIC

COMPLAINT CONTROL NUMBER: 18-AS-20210112114309

FACILITY NAME:	OAKMONT OF SAN ANTONIO HEIGHTS		FACILITY NUMBER:	366426338
ADMINISTRATOR:	ERIKA LEMON		FACILITY TYPE:	740
ADDRESS:	2419 N EUCLID AVE		TELEPHONE:	(909) 981-4002
CITY:	UPLAND	STATE: CA	ZIP CODE:	91786
CAPACITY:	140	CENSUS: 80	DATE:	11/04/2022
		UNANNOUNCED	TIME BEGAN:	10:49 AM
MET WITH:	Samuel De Guzman- Exec Director		TIME COMPLETED:	12:38 PM

ALLEGATION(S):

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Residents died after med techs administered a medication.
Resident in care sustained a fracture.
Vents are dirty.
Garbage is overflowing.
Residents are not getting their needs met.

INVESTIGATION FINDINGS:

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Licensing Program Analysts (LPAs) Natalie Ibarra and Victoria Chitgian made an unannounced visit to the facility to deliver findings for the above allegations. LPAs met with Executive Director Samuel de Guzman and explained the purpose of today’s visit. The investigation consisted on interviews with pertinent parties and records review.

The first allegation indicates residents died after med techs administered a medication. Interviews with Staff #1 (S1), Staff #2 (S2), Staff #3 (S3), and Staff #4 (S4) stated that there were no residents that died after med techs administered a medication. S1 stated there are no med techs at the facility that are 18 years old and never have been. LPA reviewed death reports for Residents #1 (R1), #2 (R2), #3 (R3), #4 (R4), #5 (R5), and #8 (R8). Residents passed away from different reasons and did not pass away on the same day. R2, R4, R5, R6, R8 and R9 were on Hospice.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Efren Malagon	TELEPHONE: (951) 202-6356
LICENSING EVALUATOR NAME: Natalie Ibarra	TELEPHONE: (951) 290-1102
LICENSING EVALUATOR SIGNATURE:	DATE: 11/04/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/04/2022

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 18-AS-20210112114309

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BERNARDINO, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: OAKMONT OF SAN ANTONIO HEIGHTS	FACILITY NUMBER: 366426338
	VISIT DATE: 11/04/2022

NARRATIVE

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The second allegation indicates resident in care sustained a fracture. Interview with S1 stated R10 had one fall in December 2020. Med-tech assess and found R10 inebriated. Medical attention was seeked immediately and R10 was sent to the hospital and diagnosed with a fractured wrist. Interview with R10 stated they have never had a fall while at the facility and that broken wrist was due to a car accident. LPAs reviewed R10s physician report that states R10 has mild cognitive impairment.

The third allegation indicates vents are dirty. Interview with S1 stated vents are changed every six (6) months and housekeeping check the vents weekly. S2, S3, and S4 stated they have never seen the vents at the facility dirty. LPA reviewed maintenance log that shows vents are being inspected and are operating every 3 months. LPAs walked the facility and did not observe vents to be dirty.

The fourth allegation indicates garbage is overflowing. Interviews with S1, S2, S3, and S4 stated the garbage at the facility is not overflowing. S1 stated that there is more trash due to covid and the use of disposable plates, cups, and utensils and a third dumpster has been ordered. S1 stated trash is picked up 6 days a week. LPAs checked the dumpsters at the facility and did not observe garbage to be overflowing.

The fifth allegation indicates residents are not getting their needs met. Interviews with S2, S3, and S4 stated residents’ needs are being met and they have never witnessed residents being left in urine and/or feces. Interviews with R10, R12, and R13 stated that their needs are being met by staff at the facility. R10 stated they have never been left in bed with feces and urine.

Based on the information obtained, the allegations are UNSUBSTANTIATED. A finding of UNSUBSTANTIATED means that although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur.

An exit interview was conducted, and a copy of this report was discussed and provided to Executive Director Samuel de Guzman.

SUPERVISOR'S NAME: Efren Malagon	TELEPHONE: (951) 202-6356
LICENSING EVALUATOR NAME: Natalie Ibarra	TELEPHONE: (951) 290-1102
LICENSING EVALUATOR SIGNATURE:	DATE: 11/04/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/04/2022

LIC9099 (FAS) - (06/04)

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