405850039-4-29-2022-29-AS-KBUY-C2BTNZ-20210422145330

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 405850039
Report Date: 04/20/2021
Date Signed: 04/29/2022 03:40:54 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, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

This is an official report of an unannounced visit/investigation of a complaint received in our office on
06/10/2020 and conducted by Evaluator Mark Jeffries

COMPLAINT CONTROL NUMBER: 29-AS-20200610141608

FACILITY NAME:	OAK PARK MANOR		FACILITY NUMBER:	405850039
ADMINISTRATOR:	MEFFERT, ASTRID		FACILITY TYPE:	740
ADDRESS:	1073 OLD OAK PARK ROAD		TELEPHONE:	(805) 540-1503
CITY:	ARROYO GRANDE	STATE: CA	ZIP CODE:	93420
CAPACITY:	32	CENSUS: 17	DATE:	04/20/2021
		UNANNOUNCED	TIME BEGAN:	01:30 PM
MET WITH:	Astrid Meffert/Administrator		TIME COMPLETED:	02:45 PM

ALLEGATION(S):

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Resident sustained multiple burns while in care.

INVESTIGATION FINDINGS:

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This is an amended report. After a higher level review, the findings were changed from substantiated to unsubstantiated. At 2:10pm on 04/20/2021, Licensing Program Analyst (LPA) Mark Jeffries issued final findings to the complaint investigation for the allegation listed above. Due to the situation surrounding the Coronavirus Disease 2019 (COVID-19), and to implement mitigation measures, today’s complaint investigation finding was conducted telephonically with Astrid Meffert the facility administrator.
As to the allegation of, “Resident sustained multiple burns while in care.” LPA conducted interviews with facility administrator and three staff on 6/11/2020 and 3/16/2021; conducted an interview with a resident on 3/16/2021; and conducted interviews with two family members on 6/11/2020.
Continued on LIC9099C

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Kelly Burley	TELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Rachael De Leon	TELEPHONE: (805) 635-4718
LICENSING EVALUATOR SIGNATURE:	DATE: 04/20/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/20/2021

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 29-AS-20200610141608

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: OAK PARK MANOR	FACILITY NUMBER: 405850039
	VISIT DATE: 04/20/2021

NARRATIVE

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This is an amended report.
LPA also reviewed facility documents and video evidence on 6/11/2020 and 4/19/2021, and medical records on 3/12/2021.
Resident 1 (R1)’s Physician Report, dated 04/03/2019, indicated that R1 had dementia and anxiety, could be confused and disoriented, and was able to feed self. The facility’s Appraisal Needs and Services (ANS) Plan, dated 05/20/2019, also stated R1 had dementia and anxiety, and did not indicate R1 needed assistance with feeding. Interviews with Administrator,
Staff 1 (S1), Staff 2 (S2), Staff 3 (S3), and Family Member 1 (F1) indicated that R1 had a specific routine of mixing hot tea and juice multiple times daily. On 05/09/2020, at approximately 10:55am, R1 requested their hot water for tea from the kitchen, per R1’s routine. S1 poured the water from the Chefman electric kettle into the cup, placed the lid on the cup and provided the cup to R1. R1 then took the cup to their recliner chair. According to interviews, R1’s juice was typically kept on R1’s walker. All staff interviewed could not verify that R1’s juice was on their walker during this incident. LPA reviewed video footage of the incident from the facility’s cameras. The video shows R1 holding the cup, without a lid, and blowing on the top of the cup. Then R1 tries to take a sip and the liquid in the cup spills on R1’s chest and lap. R1’s cup lid and juice are not visible in the video and R1’s walker does not appear to have been within R1’s reach. R1 was taken to the Emergency Room (ER) by Family Member 2 (F2) on 5/9/2020. ER medical records indicate R1 sustained first and second-degree burns on the chest and leg. The manufacturer specification of the Chefman Electric Kettle indicate that water comes to a boil (212 degrees Fahrenheit), then the kettle automatically turns off. None of the staff interviewed indicated that they tested the temperature of the water being served to R1. R1 had been doing this routine independently several times a day for years, and the facility staff would not have known R1 was likely to spill the hot tea. The facility revised their food service procedure policy for serving hot beverages to avoid future similar issues. Based on the information obtained, the allegation is deemed unsubstantiated at this time.

Exit interview conducted, copy of report and appeal rights emailed.

SUPERVISOR'S NAME: Kelly Burley	TELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Rachael De Leon	TELEPHONE: (805) 635-4718
LICENSING EVALUATOR SIGNATURE:	DATE: 04/20/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/20/2021

LIC9099 (FAS) - (06/04)

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Control Number 29-AS-20200610141608

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: OAK PARK MANOR	FACILITY NUMBER: 405850039
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 04/20/2021

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Deficiency Dismissed Type A 05/07/2021 Section Cited CCR 87468.1	1 2 3 4 5 6 7	Deficiency removed report amended.	1 2 3 4 5 6 7
	8 9 10 11 12 13 14		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: Kelly Burley	TELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Rachael De Leon	TELEPHONE: (805) 635-4718
LICENSING EVALUATOR SIGNATURE:	DATE: 04/20/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/20/2021

LIC9099 (FAS) - (06/04)

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