366426338-2-2-2023-56-AS-NBRN-CNTPAU-20230207100915

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 366426338
Report Date: 02/02/2023
Date Signed: 02/02/2023 01:16:58 PM

Unfounded

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
, CA 92507

This is an official report of an unannounced visit/investigation of a complaint received in our office on
01/27/2023 and conducted by Evaluator Amy Goldenberg

PUBLIC

COMPLAINT CONTROL NUMBER: 56-AS-20230127095330

FACILITY NAME:	OAKMONT OF SAN ANTONIO HEIGHTS		FACILITY NUMBER:	366426338
ADMINISTRATOR:	SAMUEL DE GUZMAN		FACILITY TYPE:	740
ADDRESS:	2419 N EUCLID AVE		TELEPHONE:	(909) 981-4002
CITY:	UPLAND	STATE: CA	ZIP CODE:	91786
CAPACITY:	140	CENSUS: 82	DATE:	02/02/2023
		UNANNOUNCED	TIME BEGAN:	08:50 AM
MET WITH:	Samuel De Guzman,		TIME COMPLETED:	01:30 PM

ALLEGATION(S):

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Resident fell multiple times due to staff neglect
Staff did not notify residents authorized representative of Incident in a timely manner

INVESTIGATION FINDINGS:

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This unannounced visit by Amy Goldenberg, Licensing Program Analyst (LPA), is to initiate the 10 day visit to investigate the above-mentioned complaint allegations.

During the course of this investigation LPA reviewed the facility record for R1. LPA obtained copies of seven (7) incident reports. LPA obtained a copy of the resident roster. LPA obtained copies of R1's physician's report dated 07/01/2022. LPA received and reviewed Resident Assessments dated 06/23/2022, 07/07/2022,10/01/2022, and 12/05/2022 noting meeting and careplan changes due to change of condition with R1's responsible party, facility representatives. Review of incident reports revealed that R1 had falls on 05/24/2022, 11/21/2022, 11/24/22, and 12/28/2022. LPA received and reviewed copies of R1's Resident Care Notes Dated 10/28/21 through 01/28/2023.

Unfounded

Estimated Days of Completion:

SUPERVISOR'S NAME: Nedra Brown	TELEPHONE: (951) 202-5776
LICENSING EVALUATOR NAME: Amy Goldenberg	TELEPHONE: (951) 201-3990
LICENSING EVALUATOR SIGNATURE:	DATE: 02/02/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/02/2023

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 56-AS-20230127095330

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
, CA 92507

FACILITY NAME: OAKMONT OF SAN ANTONIO HEIGHTS	FACILITY NUMBER: 366426338
	VISIT DATE: 02/02/2023

NARRATIVE

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Review of care notes dated 05/24/2022 indicate R1 pressed their call pendant after a fall and indicate that the responsible party was notified. Review of R1's resident Care Notes dated 11/21/2022 indicate that R1 pressed their pendent after a fall and that the responsible party was notified. Review of R1's resident Care Notes dated 11/24/2022 indicate that R1 returned from the hospital and within an hour was found to have had a fall and that the responsible party was notified. Review of R1's resident Care Notes dated 12/28/2022 indicate that R1 pressed their pendent after a fall and that the responsible party was notified. LPA reviewed and obtained copies of correspondence between R1's responsible party and the Health Services Director dated November 29th, 2022 through December 19th, 2022 describing R1's change of condition and service options. LPA interviewed R1 and responsible parties, noting satisfaction with the care and services R1 is receiving.

Based on review of the information obtained through interviews and review of the aforementioned documentation we have found that the evidence does not support and refutes that a violation has occurred.

We have found the complaint allegations are unfounded, meaning that the allegation was false, could not have happened and/or is without a reasonable basis. We have therefore dismissed the complaint. A copy of this report is being reviewed with and furnished to the facility representative.

SUPERVISOR'S NAME: Nedra Brown	TELEPHONE: (951) 202-5776
LICENSING EVALUATOR NAME: Amy Goldenberg	TELEPHONE: (951) 201-3990
LICENSING EVALUATOR SIGNATURE:	DATE: 02/02/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/02/2023

LIC9099 (FAS) - (06/04)

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