374603792-7-5-2022-08-AS-DPOL-CGSPF5-20220729111611

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 374603792
Report Date: 07/05/2022
Date Signed: 07/05/2022 08:27:31 AM

Unsubstantiated

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
04/24/2020 and conducted by Evaluator Elizabeth Hamilton

COMPLAINT CONTROL NUMBER: 08-AS-20200424134005

FACILITY NAME:	OAKMONT OF PACIFIC BEACH		FACILITY NUMBER:	374603792
ADMINISTRATOR:	ROXANNE GOODING		FACILITY TYPE:	740
ADDRESS:	955 GRAND AVE		TELEPHONE:	(858) 373-9300
CITY:	SAN DIEGO	STATE: CA	ZIP CODE:	92109
CAPACITY:	0	CENSUS: 0	DATE:	07/05/2022
		UNANNOUNCED	TIME BEGAN:	08:18 AM
MET WITH:	Report mailed to Licensee		TIME COMPLETED:	08:27 AM

ALLEGATION(S):

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Staff neglect resulted in resident's death

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Elizabeth Hamilton sent this report to the former licensee's last known mailing address via USPS certified mail to deliver the investigation findings for the above allegation. This facility ceased operations on July 14, 2020.

The Department’s investigation consisted of record reviews, and interviews with staff and outside sources.

On April 24, 2020, it was alleged that on April 16, 2020, staff neglect resulted in Resident 1’s (R1 See 811 – Confidential Names List) death. Interviews with staff and outside sources revealed that R1 had a fall in March 2020 while at the facility resulting in a fractured hip and rehabilitation in a skilled nursing facility. R1 returned to the facility from skilled nursing on April 1, 2020 with a change of condition resident assessment including two-hour checks. However, R1 would only need one check at the beginning of the overnight shift and one at the end as they would sleep through the night. R1 would get upset if checked on more frequently at night.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Denise Powell	TELEPHONE: (619) 301-9770
LICENSING EVALUATOR NAME: Elizabeth Hamilton	TELEPHONE: (619) 929-7590
LICENSING EVALUATOR SIGNATURE:	DATE: 07/05/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/05/2022

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 08-AS-20200424134005

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: 07/05/2022

NARRATIVE

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Records reviewed confirmed the reassessment. Interviews with staff further revealed a few weeks prior to their death, R1 was found sleeping on their floor due to increased confusion. Records reviewed confirmed R1 was diagnosed with Mild Cognitive Impairment (MCI) and could communicate their needs. On April 15, 2020, the night prior to R1’s death, when they were checked on at the beginning of the overnight shift at 11:00 pm R1 was observed as sleeping in their bed. At the second check, on April 16, 2020, at approximately 5:45 am, R1 was found unresponsive on their bedroom floor with a pillow under their head and blanket beside them. 9-1-1 was contacted; however, CPR was not performed since R1 was Do Not Resuscitate (DNR). On the night in question R1 wore a maintained alarm pendant to alert staff in case of a fall. No alert was received indicating a fall.

Records reviewed indicated R1 was a fall risk and would be managed through implementation of a fall management program; including alarm pendant and frequent checks. Records reviewed confirmed R1 was DNR according to their Physician Orders for Life-Sustaining Treatment (POLST). Additional records reviewed confirmed there was no trauma or injury to R1 to indicate a fall. The death certificate listed cause of death as complications of hip fracture post-surgery. The medical examiners office did not invoke jurisdiction. There was insufficient evidence to support the allegation staff neglect resulted or contributed to R1’s death.

The Department has investigated the allegation listed above. Based on evidence obtained, including interviews and records reviewed, the above allegation is determined to be unsubstantiated as the Department could not meet the preponderance of the evidence standard.

A copy of this report, and appeals rights (LIC 9058 1/16) were sent to the licensee's last known address on record via USPS certified mail due to facility closure.

SUPERVISOR'S NAME: Denise Powell	TELEPHONE: (619) 301-9770
LICENSING EVALUATOR NAME: Elizabeth Hamilton	TELEPHONE: (619) 929-7590
LICENSING EVALUATOR SIGNATURE:	DATE: 07/05/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/05/2022

LIC9099 (FAS) - (06/04)

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