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

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 374604281
Report Date: 11/26/2024
Date Signed: 11/26/2024 02:46:00 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN DIEGO RO, 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
01/27/2021 and conducted by Evaluator Nacole Patterson
COMPLAINT CONTROL NUMBER: 08-AS-20210127183451
FACILITY NAME:OAKMONT OF PACIFIC BEACHFACILITY NUMBER:
374604281
ADMINISTRATOR:AMIRHOUSHMAND,SHAWNFACILITY TYPE:
740
ADDRESS:955 GRAND AVETELEPHONE:
(858) 373-9300
CITY:SAN DIEGOSTATE: CAZIP CODE:
92109
CAPACITY:92CENSUS: 72DATE:
11/26/2024
UNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Kathleen Olson, Interim Executive DirectorTIME COMPLETED:
03:00 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Facility did not provide medical attention.
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Licensing Program Analyst (LPA) Nacole Patterson conducted an unannounced visit to deliver findings regarding the above complaint allegation. LPA introduced themselves and disclosed the purpose of the visit to Interim Executive Director Kathleen Olson.

On 1/27/2021 it was alleged that the facility did not provide medical attention to a resident by not initiating 911 services after the resident suffered a fall with evidence of a head injury. The Department’s investigation consisted of a virtual facility visit, an unannounced facility visit, review of facility and outside source records, interviews with facility staff, residents, and outside sources.

Staff interviews revealed that on the day of incident, Resident 1 (R1) was found sitting on the floor of their room with evidence of a head injury. Interviews further revealed that approximately one (1) hour after the fall, an outside provider arrived to the facility and initiated 911 services for R1 after contacting R1's physician, who recommended R1 be sent to the hospital. (Continued on LIC9099-C p.2)
Substantiated
Estimated Days of Completion: 0
SUPERVISOR'S NAME: Jennifer LottTELEPHONE: (619) 346-3976
LICENSING EVALUATOR NAME: Nacole PattersonTELEPHONE: (619) 767-2301
LICENSING EVALUATOR SIGNATURE:

DATE: 11/26/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/26/2024
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 6
Control Number 08-AS-20210127183451
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN DIEGO RO, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108
FACILITY NAME: OAKMONT OF PACIFIC BEACH
FACILITY NUMBER: 374604281
VISIT DATE: 11/26/2024
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
(Continued from LIC9099 p.1)

Staff involved in the incident informed that the facility policy regarding falls with evidence of a head injury required the initiation of emergency services. These same staff acknowledged that 911 services were not initiated per protocol and that it should have been done.

Outside source interviews corroborated staff interviews, informing that upon arriving to the facility, the outside provider contacted R1's physician and then 911 approximately one (1) hour after R1's fall. Outside sources confirmed that evidence of a head injury existed due to R1 having a forehead wound, which was covered by a bandage.

The Unusual Incident/Injury Report submitted by the facility regarding the incident corroborated interview statements that the outside source contacted 911 for further evaluation of R1 after the fall. Review of facility document, "Falls Quick Reference Guide", revision date December 2013, stated, "If a licensed nurse is not immediately available, observe the resident for the following: ...The resident tells you, or was observed, or it appears, that they hit their head...If any of the above signs are present - Do not move resident, call 911 immediately". Staff knowledge and understanding of this rule was confirmed through interviews. Review of R1's hospital admission records the day of the incident showed that R1 was admitted for evaluation after a fall with head injury. The medical records showed that R1 was assessed to have a closed head injury and abrasion. These records confirm that staff did not follow facility protocol regarding falls with evidence of a head injury. While R1 ultimately did receive 911 medical care, the initiation of assistance was due to the outside provider who visited R1 the day of incident, not facility staff.

Based on relevant interviews and records review, the preponderance of evidence has been met that alleged violation occurred and is therefore substantiated. Deficiencies are cited per California Code of Regulations, Title 22 (refer to the attached LIC9099-D). A Plan of Correction was jointly developed with the licensee. An exit interview was conducted with Interim Executive Director Kathleen Olson, to whom a copy of this report and the Licensee/Appeal Rights (LIC9058 03/22) were provided.
SUPERVISOR'S NAME: Jennifer LottTELEPHONE: (619) 346-3976
LICENSING EVALUATOR NAME: Nacole PattersonTELEPHONE: (619) 767-2301
LICENSING EVALUATOR SIGNATURE:

DATE: 11/26/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/26/2024
LIC9099 (FAS) - (06/04)
Page: 6 of 6
Control Number 08-AS-20210127183451
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

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

FACILITY NAME: OAKMONT OF PACIFIC BEACH
FACILITY NUMBER: 374604281
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/26/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
12/06/2024
Section Cited
CCR
87465(a)(1)
1
2
3
4
5
6
7
87465(a)(1) The licensee shall arrange, or assist in arranging, for medical and dental care appropriate to the conditions and needs of residents.

This requirement was not met, as evidenced by:
1
2
3
4
5
6
7
Executive Director agreed to coordinate retraining for all direct service staff regarding the facility’s fall policy, to specifically include circumstances where there is evidence of a head injury and initiation of 911 services.
8
9
10
11
12
13
14
Based on records review and interviews, Licensee did not assist in arranging medical care appropriate to the conditions and needs for 1 out of 60 residents (R1). This posed an immediate health risk to persons in care.
8
9
10
11
12
13
14
 The training sign-in sheet(s) will be submitted to LPA by the POC due date, as proof.
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: Jennifer LottTELEPHONE: (619) 346-3976
LICENSING EVALUATOR NAME: Nacole PattersonTELEPHONE: (619) 767-2301
LICENSING EVALUATOR SIGNATURE:

DATE: 11/26/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/26/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 6
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN DIEGO RO, 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
01/27/2021 and conducted by Evaluator Nacole Patterson
COMPLAINT CONTROL NUMBER: 08-AS-20210127183451

FACILITY NAME:OAKMONT OF PACIFIC BEACHFACILITY NUMBER:
374604281
ADMINISTRATOR:AMIRHOUSHMAND,SHAWNFACILITY TYPE:
740
ADDRESS:955 GRAND AVETELEPHONE:
(858) 373-9300
CITY:SAN DIEGOSTATE: CAZIP CODE:
92109
CAPACITY:92CENSUS: 72DATE:
11/26/2024
UNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Interim Executive Director Kathleen OlsonTIME COMPLETED:
03:00 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Facility staff not meeting client's needs.
Facility staff did not provide client supervision resulting in injuries.
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Licensing Program Analyst (LPA) Nacole Patterson conducted an unannounced visit to deliver findings regarding the above complaint allegations. LPA introduced themselves and disclosed the purpose of the visit to Interim Executive Director Kathleen Olson.

On 01/27/2021 it was alleged that facility staff did not meet a client's needs and did not provide supervision, which resulted in injuries. The Department’s investigation consisted of a virtual facility visit, an unannounced facility visit, review of facility and outside source records, interviews with facility staff, residents, and outside sources.

Regarding the allegation, "Facility staff not meeting client's needs", it was alleged that staff did not assist Resident 1 (R1) with tasks such as eating meals and using their cell phone. R1's care plan dated 12/3/2020 revealed that R1 did not need caregiver assistance with eating and use of a telephone.
(Continued on LIC9099-C p.2)
Unsubstantiated
Estimated Days of Completion: 0
SUPERVISOR'S NAME: Jennifer LottTELEPHONE: (619) 346-3976
LICENSING EVALUATOR NAME: Nacole PattersonTELEPHONE: (619) 767-2301
LICENSING EVALUATOR SIGNATURE:

DATE: 11/26/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/26/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 3 of 6
Control Number 08-AS-20210127183451
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN DIEGO RO, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108
FACILITY NAME: OAKMONT OF PACIFIC BEACH
FACILITY NUMBER: 374604281
VISIT DATE: 11/26/2024
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
(Continued from LIC9099 p.1)

R1's Physician's Report dated 12/2/2020 revealed that R1 was "Able to feed self” and did not indicate that R1 needed help with tasks such as using their cell phone. These documents do not corroborate the allegation, as they do not show an expectation that staff were responsible for feeding R1 or assisting with the use of R1's cell phone.

Staff interviews were consistent regarding R1's assistance needs. Staff informed that R1 required assistance with Activities of Daily Living (ADLs), specifically noting transferring in and out of bed to wheelchair, dressing, toileting and bathing. Interviews with staff regarding services provided to R1 were consistent with R1's needs listed in the Physician's Report and facility assessment. Staff interviews did not provide corroboration to the allegation.

During interview R1's Responsible Party did not corroborate the allegation. R1's Responsible Party stated that facility staff did a wonderful job caring for R1, and that R1 was thriving at the facility.

Interview with R1 did not corroborate the allegation. R1 informed that staff treated them well and did not inform of any services denied to them by facility staff.

Regarding the allegation, "Facility staff did not provide client supervision resulting in injuries", it was alleged that staff neglect resulted in R1 falling seven (7) to ten (10) times during the timeframe of complaint. Staff and outside source interviews did not corroborate this allegation, informing that R1 had never fallen from a standing position due to not being able to walk or stand without assistance.

Review of facility records did not corroborate that the resident fell 7-10 times. Evidence shows that the resident fell once on 12/11/2020, suffering a head injury without immediate 911 initiation from staff. This incident was investigated by the Department and the facility was cited for failure to assist with medical care.

During interview the reporting party admitted that they did not directly witness the alleged falls and had not found R1 on the floor or with injuries, with the exception of R1's fall on 12/11/2020. Outside sources further revealed that R1's claims of falling may have been a hallucination due to a medical condition.

Review of R1's Physician Report and facility assessment showed that R1 required assistance with transferring in and out of bed to wheelchair, bathing, and specific Activities of Daily Living (ADLs) such as putting on pants. No records were found to show that facility staff neglected to consistently provide these services to R1. (Continued on LIC9099-C p.3)

SUPERVISOR'S NAME: Jennifer LottTELEPHONE: (619) 346-3976
LICENSING EVALUATOR NAME: Nacole PattersonTELEPHONE: (619) 767-2301
LICENSING EVALUATOR SIGNATURE:

DATE: 11/26/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/26/2024
LIC9099 (FAS) - (06/04)
Page: 5 of 6
Control Number 08-AS-20210127183451
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN DIEGO RO, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108
FACILITY NAME: OAKMONT OF PACIFIC BEACH
FACILITY NUMBER: 374604281
VISIT DATE: 11/26/2024
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
(Continued from LIC9099-C p.2)

During interview R1's Responsible Party did not corroborate the allegation. R1's Responsible Party stated that facility staff did a wonderful job caring for R1, and that R1 was thriving at the facility.

Interview with R1 did not corroborate the allegation. R1 informed that staff treated them well and did not inform of any numerous falls or lack of supervision by facility staff.

Based on interviews and records review, a preponderance of evidence does not exist to prove that the alleged violations occurred, therefore the allegations are UNSUBSTANTIATED. An exit interview was conducted with Interim Executive Director Kathleen Olson, to whom a copy of this report and the Licensee/Appeal Rights (LIC9058 03/22) were provided.

SUPERVISOR'S NAME: Jennifer LottTELEPHONE: (619) 346-3976
LICENSING EVALUATOR NAME: Nacole PattersonTELEPHONE: (619) 767-2301
LICENSING EVALUATOR SIGNATURE:

DATE: 11/26/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/26/2024
LIC9099 (FAS) - (06/04)
Page: 4 of 6