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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374604457
Report Date: 11/02/2022
Date Signed: 11/02/2022 05:59:43 PM


Document Has Been Signed on 11/02/2022 05:59 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, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507



FACILITY NAME:OAKMONT OF ESCONDIDO HILLSFACILITY NUMBER:
374604457
ADMINISTRATOR:BRENNAN, JOHNFACILITY TYPE:
740
ADDRESS:3012 BEAR VALLEY PARKWAYTELEPHONE:
(760) 735-8084
CITY:ESCONDIDO HILLSSTATE: CAZIP CODE:
92025
CAPACITY:160CENSUS: 120DATE:
11/02/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
04:20 PM
MET WITH:Executive Director, John BrennanTIME COMPLETED:
06:00 PM
NARRATIVE
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Licensing Program Analyst (LPA) Janira Arreola conducted an unannounced visit to the facility in order to conduct a follow-up on an incident report that was received on 10/31/2022 for Resident #1 (R1). LPA met with John Brennan, Executive Director who was informed of the purpose of the visit.

During the visit LPA reviewed R1's file, interviewed staff and gathered documentation pertaining to the incident report. LPA observed that progress notes were documented on 10/13/2022 and again on 10/14/2022 for home health to check R1 for a wound. LPA observed on 10/25/2022 this visit was conducted and R1 was transferred to hospital. It was found through interviews that there were no prior reports to 10/13/2022 for the incident reported or documented for a wound. It was also found that the resident was appraised for hospice services after 10/25/2022. The resident was not on hospice or Home health services prior to 10/25/2022. LPA reviewed documentation for progress notes on 10/25/2022 stating that the wound was unstagable.

Therefore based on the above, the facility will be cited for failure to reappraise resident for change in condition. This will be documented on an LIC809-D page along with the plan of correction.

An exit interview was conducted were this report along with 809-D page, and appeal rights were reviewed and provided to executive director, John Brennan.
SUPERVISOR'S NAME: Joel EsquivelTELEPHONE: (951) 202-5067
LICENSING EVALUATOR NAME: Janira ArreolaTELEPHONE: 951-248-2222
LICENSING EVALUATOR SIGNATURE:
DATE: 11/02/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/02/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2


Document Has Been Signed on 11/02/2022 05:59 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, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507


FACILITY NAME: OAKMONT OF ESCONDIDO HILLS
FACILITY NUMBER: 374604457

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/02/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Request Denied
Type A
11/03/2022
Section Cited
CCR
87463(a)(3)

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87463 Reappraisals(a)The pre-admission appraisal shall be updated...Significant changes shall include but not be limited to: (3) Any illness, injury, trauma, or change in the health care needs of the resident that results in a circumstance or condition specified in Sections 87455(c) or 87615, Prohibited Health Conditions. This requirment was not met as evidenced by:
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Licensee shall submit to LPA a written statement that the facility will document any changes in the residents condition by the POC due date.
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 This requirment was not met as evidenced by:
Based on interview and records review the facility failed to provide the appropraite reappriasal for the resident resulting in an unstangable wound. This is an immedicate health, saftey or personal rights risk.
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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: Joel EsquivelTELEPHONE: (951) 202-5067
LICENSING EVALUATOR NAME: Janira ArreolaTELEPHONE: 951-248-2222
LICENSING EVALUATOR SIGNATURE:
DATE: 11/02/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/02/2022
LIC809 (FAS) - (06/04)
Page: 2 of 2