565850108-2-7-2022-29-AS-KHEN-CBXU9Z-20220224142359

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 565850108
Report Date: 02/07/2022
Date Signed: 02/07/2022 05:39:12 PM

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
02/02/2022 and conducted by Evaluator Kelly Dulek

COMPLAINT CONTROL NUMBER: 29-AS-20220202092811

FACILITY NAME:	OAK PLACE RESIDENTIAL CARE		FACILITY NUMBER:	565850108
ADMINISTRATOR:	SPRING, BECKY		FACILITY TYPE:	740
ADDRESS:	50 OAK ST.		TELEPHONE:	(805) 586-4086
CITY:	CAMARILLO	STATE: CA	ZIP CODE:	93010
CAPACITY:	36	CENSUS: 36	DATE:	02/07/2022
		UNANNOUNCED	TIME BEGAN:	02:30 PM
MET WITH:	Flordeliza Hipolito & Becky Spring		TIME COMPLETED:	05:45 PM

ALLEGATION(S):

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Facility staff failed to seek timely medical attention for resident
Facility staff failed to assist resident with hygeine needs
Licensee failed to maintain facility odor free

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Kelly Dulek conducted an initial complaint investigation for the allegations listed above. LPA arrived at the facility at 02:30PM and met with facility staff Flordeliza Hipolito, who is authorized to sign reports. Entrance interview conducted. Administrator Becky Spring arrived at the facility at 05:05PM.

During today's visit, LPA conducted an interview with facility staff at 02:37PM and from 04:22PM to 04:33PM, toured the facility with staff Flordeliza Hipolito at 03:00PM, conducted resident interviews from 03:13 PM until 04:05PM, and interviewed Resident #1 (R1)'s responsible party at 04:06PM and R1's case manager at 04:40PM. LPA received and reviewed copies of documents pertinent to the investigation.

The following was then concluded:
Interviews with staff and other pertinent parties and record review revealed that R1 is their own responsible
Report Continued on LIC 9099-C

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME:	TELEPHONE:
LICENSING EVALUATOR NAME: Kelly Dulek	TELEPHONE:
LICENSING EVALUATOR SIGNATURE:	DATE: 02/07/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/07/2022

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-20220202092811

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: OAK PLACE RESIDENTIAL CARE	FACILITY NUMBER: 565850108
	VISIT DATE: 02/07/2022

NARRATIVE

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party and makes their own decisions. R1 regularly refused care, including incontinence care, hygiene assistance, and assistance with Activities of Daily Living (ADLs.) On the day of the incident, staff noticed R1 required medical attention, but R1 refused care. R1 continued to refuse care, but eventually agreed when R1's family member was called and spoke with R1. All 4 of 4 residents interviewed all indicated that the facility assists with medical concerns in a timely manner. Based on interviews and record review, there is insufficient evidence to support the allegation; therefore, the allegation that "facility staff failed to seek timely medical attention for resident" is deemed UNSUBSTANTIATED at this time.

Staff interviews revealed that residents are assisted regularly throughout the day and as needed with their incontinence needs. Residents are regularly assisted with showers between 3-4 times per week. Staff assist residents daily with all other ADLs. Interviews revealed that R1 regularly refused care and that R1's family member would convince and offer incentives to R1 to allow staff to assist with hygiene needs. Other pertinent parties indicated even prior to residing at this facility, R1 would refuse to take care of their own hygiene needs and refuse assistance as well. Documents reviewed corroborated R1's refusal of assistance with hygiene needs. Based on interviews and record review, there is insufficient evidence to support the allegation; therefore, the allegation that "Facility staff failed to assist resident with hygiene needs" is deemed UNSUBSTANTIATED at this time.

During facility tour, LPA Dulek did not notice any areas contain unpleasant odors. Interviews revealed that although facility house rules prohibit smoking indoors, some residents, including R1 have been caught smoking inside resident rooms or residents open their doors and smoke just outside their rooms at times. Some residents indicated that previously the facility had an unpleasant odor, but it has been a number of years since this was a concern. Based on interviews and observation, there is insufficient evidence to prove the allegation; therefore, the allegation that "Licensee failed to maintain facility odor free" is deemed UNSUBSTANTIATED at this time.

Exit interview was conducted with Administrator Becky Spring. Report was provided via email.

SUPERVISOR'S NAME:	TELEPHONE:
LICENSING EVALUATOR NAME: Kelly Dulek	TELEPHONE:
LICENSING EVALUATOR SIGNATURE:	DATE: 02/07/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/07/2022

LIC9099 (FAS) - (06/04)

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