<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 374603792
Report Date: 04/15/2021
Date Signed: 04/15/2021 05:18:15 PM



STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108
This is an official report of an unannounced visit/investigation of a complaint received in our office on
03/05/2020 and conducted by Evaluator Elizabeth Hamilton
COMPLAINT CONTROL NUMBER: 08-AS-20200305101740
FACILITY NAME:OAKMONT OF PACIFIC BEACHFACILITY NUMBER:
374603792
ADMINISTRATOR:ROXANNE GOODINGFACILITY TYPE:
740
ADDRESS:955 GRAND AVETELEPHONE:
(858) 373-9300
CITY:SAN DIEGOSTATE: CAZIP CODE:
92109
CAPACITY:0CENSUS: 0DATE:
04/15/2021
UNANNOUNCEDTIME BEGAN:
03:27 PM
MET WITH:Senior Vice Present of Regulatory Affairs, Susan McPherson TIME COMPLETED:
03:43 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Reporting Requirements
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Licensing Program Analyst (LPA), Elizabeth Hamilton, conducted an unannounced complaint investigation virtual visit via Zoom due to COVID-19. LPA identified herself and discussed the purpose of the visit, which was to deliver findings for the above allegation with Senior Vice President of Regulatory Affairs, Susan McPherson.

The Department’s investigation consisted of facility and medical records review, and interviews with staff and outside sources.

It was alleged that the facility did not report accurately to Community Care Licensing Division (CCLD) regarding an incident that occurred on December 02, 2019. Interviews revealed Resident 1 (R1 – See LIC 811 Confidential Names List) was found on the floor in their apartment with R2 and R3 present. Records reviewed confirmed that the facility reported an incident to the Department on December 09, 2019 regarding an unobserved fall in R1’s apartment, however, did not include R2 and R3 being present during the incident.
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Denise PowellTELEPHONE: (619) 301-9770
LICENSING EVALUATOR NAME: Elizabeth HamiltonTELEPHONE: (619) 929-7590
LICENSING EVALUATOR SIGNATURE:

DATE: 04/15/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/15/2021
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 5
Control Number 08-AS-20200305101740
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108
FACILITY NAME: OAKMONT OF PACIFIC BEACH
FACILITY NUMBER: 374603792
VISIT DATE: 04/15/2021
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
On February 27, 2020, the facility submitted an update to the previous incident report which included the two residents being in the area during the incident and due to their cognitive levels, they were unable to provide information. Interviews with staff revealed the information of R2 and R3 being present in the room was known and reported up, however, not initially noted on the Incident Report submitted to CCLD as the Health Services Director indicated R2 and R3 were not involved in the unobserved incident. Investigation could not confirm if R2 and/or R3 were involved in the unobserved incident which resulted in R1’s fall and torn ligament.

The Department has investigated the allegation of facility not reporting the nature of the event. Based on evidence obtained, including interviews and records reviewed the allegation is substantiated which means that the allegation is valid because the preponderance of the evidence standard has been met. A deficiency is cited in accordance of California Code of Regulations, Title 22, Division 6 Chapter 8, and listed on the 9099D. The Plan of Correction is cleared due to facility closure.

An exit interview was conducted with Susan McPherson via Zoom and a copy of this report, confidential names list and Licensee/Appeals Rights (LIC 9058 01/16) was provided to Susan McPherson via email. An electronic receipt of confirmation was requested to be sent by Senior Vice President of Regulatory Affairs upon receipt of the documents.
SUPERVISOR'S NAME: Denise PowellTELEPHONE: (619) 301-9770
LICENSING EVALUATOR NAME: Elizabeth HamiltonTELEPHONE: (619) 929-7590
LICENSING EVALUATOR SIGNATURE:

DATE: 04/15/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/15/2021
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 08-AS-20200305101740
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108

FACILITY NAME: OAKMONT OF PACIFIC BEACH
FACILITY NUMBER: 374603792
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/15/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
04/15/2021
Section Cited
CCR
87211(a)(1)
1
2
3
4
5
6
7
87211(a)(1) Reporting Requirements: A written report shall be submitted to the licensing agency... This report shall include the resident's name, age, sex and date of admission; date and nature of event; attending physician's name, findings, and treatment, if any; and disposition of the case.
1
2
3
4
5
6
7
The facility closed effective July 14, 2020. The deficiency is cleared.
8
9
10
11
12
13
14
Based on interviews and records reviewed, licensee did not report the nature of event as occurred to the Department. This posed a potential impact on the facility’s operation.
8
9
10
11
12
13
14
1
2
3
4
5
6
7
1
2
3
4
5
6
7
1
2
3
4
5
6
7
1
2
3
4
5
6
7
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Denise PowellTELEPHONE: (619) 301-9770
LICENSING EVALUATOR NAME: Elizabeth HamiltonTELEPHONE: (619) 929-7590
LICENSING EVALUATOR SIGNATURE:

DATE: 04/15/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/15/2021
LIC9099 (FAS) - (06/04)
Page: 3 of 5
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108
This is an official report of an unannounced visit/investigation of a complaint received in our office on
03/05/2020 and conducted by Evaluator Elizabeth Hamilton
COMPLAINT CONTROL NUMBER: 08-AS-20200305101740

FACILITY NAME:OAKMONT OF PACIFIC BEACHFACILITY NUMBER:
374603792
ADMINISTRATOR:ROXANNE GOODINGFACILITY TYPE:
740
ADDRESS:955 GRAND AVETELEPHONE:
(858) 373-9300
CITY:SAN DIEGOSTATE: CAZIP CODE:
92109
CAPACITY:0CENSUS: 0DATE:
04/15/2021
UNANNOUNCEDTIME BEGAN:
03:27 PM
MET WITH:Senior Vice Present of Regulatory Affairs, Susan McPherson TIME COMPLETED:
03:43 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Lack of supervision resulted in resident being physically assaulted causing an injury
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Licensing Program Analyst (LPA) Elizabeth Hamilton conducted an unannounced complaint investigation virtual visit via Zoom due to COVID-19. LPA identified herself and discussed the purpose of the visit, which was to deliver findings for the above allegation with Senior Vice President of Regulatory Affairs, Susan McPherson.

The Department’s investigation consisted of facility and medical records review, and interviews with staff and outside sources.

It was alleged that on December 02, 2019, staff lacked care and supervision resulting in Resident 1 (R1 – See LIC 811 Confidential Names List) being physically assaulted causing an injury. Interviews revealed R1 went to their apartment to get ready for dinner after a group activity. Shortly after, they yelled for help and were found on the floor in their apartment with R2 and R3 present. R1 reported they were pushed by R2 or R3. Staff reported one of residents present verbalized attempting to help R1.
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Denise PowellTELEPHONE: (619) 301-9770
LICENSING EVALUATOR NAME: Elizabeth HamiltonTELEPHONE: (619) 929-7590
LICENSING EVALUATOR SIGNATURE:

DATE: 04/15/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/15/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 08-AS-20200305101740
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108
FACILITY NAME: OAKMONT OF PACIFIC BEACH
FACILITY NUMBER: 374603792
VISIT DATE: 04/15/2021
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
Staff called emergency services and R1 was transported to the Hospital and ultimately diagnosed with a ligament tear. The incident was unobserved by staff and a later interview by facility management revealed R1, R2 and R3 were unable to recall the incident due to having diagnoses dementia. Interviews conducted established staff observed R1, R2 and R3 ten to fifteen minutes prior to the incident which is within the facility policy of hourly checks for memory care residents. Records reviewed confirmed R1, R2 and R3 had diagnoses of dementia. Records further revealed staff followed the residents’ care plans and properly responded to the incident. Due to the circumstances, the exact details of the incident could not be determined as all were memory care residents. It is unknown if R1 had fallen or was pushed, however, it was not determined to be a result of lack of supervision.

The Department has investigated the alleged staff lack of supervision resulting in R1 being physically assaulted causing an injury. Based on evidence obtained, including interviews and records reviewed the allegation is unsubstantiated as the Department could not meet the preponderance of the evidence standard.

An exit interview was conducted with Susan McPherson via Zoom and a copy of this report, confidential names list and Licensee/Appeals Rights (LIC 9058 01/16) was provided to Susan McPherson via email. An electronic receipt of confirmation was requested to be sent by the Resident Services Director upon receipt of the documents.
SUPERVISOR'S NAME: Denise PowellTELEPHONE: (619) 301-9770
LICENSING EVALUATOR NAME: Elizabeth HamiltonTELEPHONE: (619) 929-7590
LICENSING EVALUATOR SIGNATURE:

DATE: 04/15/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/15/2021
LIC9099 (FAS) - (06/04)
Page: 5 of 5