374604457-10-31-2024-08-AS-JLOT-DAL3X2-20241031183736

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 374604457
Report Date: 10/31/2024
Date Signed: 10/31/2024 01:10:12 PM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office,
, CA

This is an official report of an unannounced visit/investigation of a complaint received in our office on
12/20/2021 and conducted by Evaluator Debbie Correia

COMPLAINT CONTROL NUMBER: 08-AS-20211220132223

FACILITY NAME:	OAKMONT OF ESCONDIDO HILLS		FACILITY NUMBER:	374604457
ADMINISTRATOR:	BRENNAN, JOHN		FACILITY TYPE:	740
ADDRESS:	3012 BEAR VALLEY PARKWAY		TELEPHONE:	(760) 735-8084
CITY:	ESCONDIDO HILLS	STATE: CA	ZIP CODE:	92025
CAPACITY:	160	CENSUS: 131	DATE:	10/31/2024
		UNANNOUNCED	TIME BEGAN:	12:00 PM
MET WITH:	Executive Director John Brennan		TIME COMPLETED:	12:45 PM

ALLEGATION(S):

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Staff neglect resulted in a resident being hospitalized.
Resident left soiled for an extended period of time while in care.
Staff are not following a resident's needs and services plan.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Debbie Correia conducted an unannounced visit to conclude a complaint investigation. LPA was granted entry after identifying herself and discussed the purpose of the visit with*.

The Department's investigation included resident, facility, and outside source records reviews and interviews.

It was alleged that staff neglect resulted in Resident 1 (R1) being admitted to several hospital stays. A resident records review revealed R1 was admitted to the facility on November 1, 2016, with a primary diagnosis of paralysis to their left side of their body from suffering a stroke. Review of resident records revealed R1 required assistance with dressing and ambulation due to their paralysis. Resident records reviews and an interview with Staff 1 (S1) the Service Health Director, revealed R1 is a two person assist, required a lift for transfers to use the bathroom and for showers.

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Simon Jacob
LICENSING EVALUATOR NAME: Debbie Correia
LICENSING EVALUATOR SIGNATURE:	DATE: 10/31/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/31/2024

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 3

Control Number 08-AS-20211220132223

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office,
, CA

FACILITY NAME: OAKMONT OF ESCONDIDO HILLS	FACILITY NUMBER: 374604457
	VISIT DATE: 10/31/2024

NARRATIVE

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The interview with S1 also revealed besides R1 requiring assistance with mobility R1 was independent, oriented, and active in the community. An interview conducted with Outside Source 1 (OS1) on February 6, 2022, revealed facility staff did not conduct incontinence care in a timely manner that resulted in several recent hospital stays to treat R1 for Urinary Tract Infections (UTIs). A review of facility and Outside Source 2 (OS2) records revealed R1 had no recent hospital stays from October 1, 2021, to the time the complaint was filed on December 21, 2021. An interview conducted with Outside Source 3 (OS3) confirmed R1 had no recent hospital records per the given time frame and R1’s last hospital visit was on September 22, 2020. An interview with Outside Source 4 (OS4) corroborated R1 had no hospitalizations or serious medical conditions that was a result from UTIs.

It was also alleged facility staff left R1 in soiled undergarments for an extended period. Resident records reviews and an interview conducted with S1 on December 30, 2021, revealed on an occasion (date unknown) R1 was having bowel problems and was found in soiled undergarments. S1 revealed they had expressed to R1 the importance of using their pendant for assistance when they had soiled undergarments, in response R1 revealed that they were unable to feel when they were soiled due to their paralysis. The interview conducted with S1 revealed upon R1 revealing not being able to feel when they were soiled, R1 underwent a re-assessment and their care plan was updated to increased frequencies of checks and incontinence care provided by staff.

Additionally, it was alleged facility staff did not follow R1’s needs and service plan. A resident records review of R1 revealed between January of 2020 and December of 2021, R1 had a total of three (3) reassessments to gage their level of care and updated their care plan accordingly to ensure R1 care needs were met. Further review of R1’s records revealed on December 12, 2021, R1 had undergone a change in condition and in agreement with R1’s Responsible Party, R1’s care plan was updated to providing 2-hour checks for incontinence care. Interviews with facility staff were conducted on December 30, 2021, revealed the following information. An interview conducted with Staff 2 (S2) revealed when providing care and supervision for R1 they would check on R1 every two hours as directed and changed R1’s undergarments as needed. S2 also revealed they responded to R1’s pendent calls within 5 minutes. S2 stated they enjoyed talking to R1 and did not mind doing more care tasks to keep R1 comfortable.

SUPERVISORS NAME: Simon Jacob
LICENSING EVALUATOR NAME: Debbie Correia
LICENSING EVALUATOR SIGNATURE:	DATE: 10/31/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/31/2024

LIC9099 (FAS) - (06/04)

Page: 2 of 3

Control Number 08-AS-20211220132223

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office,
, CA

FACILITY NAME: OAKMONT OF ESCONDIDO HILLS	FACILITY NUMBER: 374604457
	VISIT DATE: 10/31/2024

NARRATIVE

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An interview conducted with Staff 3 (S3) revealed they worked as on-call staff to provide extra support when needed. S3 revealed they would respond to pendent calls within 5 minutes to ensure immediate assistance needed by residents, including R1, were met. An interview conducted with Staff 4 (S4) revealed they recently began working at the facility in November 2021. S4 also revealed they frequently responded to R1’s pendent calls as they would call for assistance for small task, in addition S4 would conduct checks every two hours to ensure R1 was dry and clean per direction from the Service Health Director. An interview conducted with Staff 5 (S5) revealed they were routinely assigned to provide care for R1 and would conduct frequent checks, assist them with showers, and changed their undergarments to ensure R1 was kept clean and dry. An interview conducted with R1 on January 15, 2022, revealed they were doing really well and facility staff had been checking on them frequently. [See LIC 811 for confidential names]

Due to lack of corroborating evidence, the finding regarding the above allegations were established to be unsubstantiated. This finding means although the allegations may have happened or could be valid, there is not a preponderance of evidence to prove that the alleged violations occurred.

LPA Correia conducted an exit interview with ED Brennan. At the time of the exit interview ED Brennan was advised a copy of the Complaint Investigation Report (LIC9099) and Licensee Rights (LIC9058 01-2016) will be provided and signature on this report acknowledges receipt of the rights.

SUPERVISORS NAME: Simon Jacob
LICENSING EVALUATOR NAME: Debbie Correia
LICENSING EVALUATOR SIGNATURE:	DATE: 10/31/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/31/2024

LIC9099 (FAS) - (06/04)

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