374604281-7-17-2023-08-AS-DNGN-CTTRJR-20230717130422

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 374604281
Report Date: 07/17/2023
Date Signed: 07/17/2023 01:05:05 PM

Document Has Been Signed on 07/17/2023 01:05 PM - 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, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108

FACILITY NAME:	OAKMONT OF PACIFIC BEACH		FACILITY NUMBER:	374604281
ADMINISTRATOR:	CAROLINE SENTENO		FACILITY TYPE:	740
ADDRESS:	955 GRAND AVE		TELEPHONE:	(858) 373-9300
CITY:	SAN DIEGO	STATE: CA	ZIP CODE:	92109
CAPACITY:	92	CENSUS: 76	DATE:	07/17/2023
TYPE OF VISIT:	Case Management - Incident	UNANNOUNCED	TIME BEGAN:	09:30 AM
MET WITH:	Executive Director Caroline Senteno and Business Office Director William Lopeman		TIME COMPLETED:	12:10 PM

NARRATIVE

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Licensing Program Analyst (LPA) Dang Nguyen conducted an unannounced Case Management – Incident visit. LPA was welcomed by, identified himself to, and discussed the purpose of the visit with Business Office Director William Lopeman. LPA then met and spoke with Executive Director Caroline Senteno, who arrived shortly after.

Today's visit was in response to an LIC624 Incident Report, which licensee self-submitted to the CCLD San Diego Regional Office (received 07/03/2023). According to the LIC624: on the evening of 06/21/2023, a joint error by Staff #1 (S1) and Staff #2 (S2) led to Resident #1 (R1) eating/ingesting a topical cream, rather than that cream being applied to their skin (which is how it was prescribed). [See LIC 811 Confidential Names List for a description of person identifiers used in this report]. R1 was sent to a local hospital via 911 for further evaluation.

During today’s visit, LPA performed a brief facility tour and welfare check on R1, verifying that they were safe. LPA reviewed pertinent care, administrative, and hospital records. LPA also interviewed R1 and relevant staff.

Per their latest LIC602 Physician’s Report (dated 02/28/2023), R1 was diagnosed with “Lewy Body Dementia” and required staff assistance with taking their prescribed medications. Per assessment/care plan (dated 05/12/2023) which Licensee authored, R1 experienced forgetfulness and confusion and required staff assistance with taking their prescribed medications. Despite R1’s dementia diagnosis, they were alert and oriented enough participate as a reliable historian/interviewee about the incident.

[CONTINUED ON LIC 809-C]

SUPERVISOR'S NAME: Lizzette Tellez	TELEPHONE: (619) 767-2351
LICENSING EVALUATOR NAME: Dang Nguyen	TELEPHONE: (619) 210-9024
LICENSING EVALUATOR SIGNATURE:	DATE: 07/17/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/17/2023

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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Document Has Been Signed on 07/17/2023 01:05 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 374604281
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 07/17/2023

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 08/16/2023 Section Cited CCR 87465(a)(4)	1 2 3 4 5 6 7	87465 Incidental Medical and Dental Care: “(a)(4) The licensee shall assist residents with self-administered medications as needed.” This requirement was not met, as evidenced by:	1 2 3 4 5 6 7	Based on records and interviews: a) on 06/22/2023, Licensee disciplined and/or counseled S1 and S2 regarding the incident, and b) on 07/13/2023, Licensee retrained its med tech team at large on accurate medication pass procedures. These actions resolve the deficiency.
	8 9 10 11 12 13 14	Based on records and interviews, the licensee did not assist 1 of 76 residents (R1) with self-administered medications as needed/prescribed, which posed a potential health risk to persons in care.	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: Lizzette Tellez	TELEPHONE: (619) 767-2351
LICENSING EVALUATOR NAME: Dang Nguyen	TELEPHONE: (619) 210-9024
LICENSING EVALUATOR SIGNATURE:	DATE: 07/17/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/17/2023

LIC809 (FAS) - (06/04)

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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 374604281
	VISIT DATE: 07/17/2023

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[CONTINUED FROM LIC 809]

Interviews, corroborated by records, showed: S1 did not follow internal medication procedure, and miscommunication occurred between S1 and S2, which materially contributed to R1 being able to ingest the cream. Facility staff timely notified R1’s prescribing physician and responsible party. R1 developed abdominal pain, and 911 was timely called. R1 was evaluated at a nearby hospital but was not admitted overnight. After R1 discharged back to the facility, staff continued to observe them. R1 had no further physical complaints/problems. Prior to LPA’s site visit, Licensee had formally disciplined S1 and provided verbal coaching/counseling to S2, based on its internal investigation of the incident. Licensee had also retrained its medication technician team at large on accurate medication pass policies/procedures.

A preponderance of evidence exists to show that during the above incident, Licensee’s staff did not give R1 their medication via the route that it was prescribed. The medication error triggered temporary abdominal pain, but did not result in lasting injury/illness to R1. One (1) deficiency was cited per California Code of Regulations, Title 22 (refer to the LIC 809-D page). A Plan of Correction was jointly developed with the licensee. LPA also issued one (1) Technical Violation regarding Reporting Requirements (refer to the LIC 9102-TV page).

An exit interview was conducted with Senteno, to whom a copy of this report, the LIC 809-D, the LIC 9102-TV, the LIC811 Confidential Names List, and the Licensee/Appeal Rights (LIC9058 03/22) were provided during the visit.

SUPERVISOR'S NAME: Lizzette Tellez	TELEPHONE: (619) 767-2351
LICENSING EVALUATOR NAME: Dang Nguyen	TELEPHONE: (619) 210-9024
LICENSING EVALUATOR SIGNATURE:	DATE: 07/17/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/17/2023

LIC809 (FAS) - (06/04)

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