565850168-5-5-2023-29-AS-JAPL-CRJV99-20230505161358

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 565850168
Report Date: 05/04/2023
Date Signed: 05/05/2023 08:27:03 AM

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
06/27/2022 and conducted by Evaluator Teresa Camara

COMPLAINT CONTROL NUMBER: 29-AS-20220627090021

FACILITY NAME:	OAKMONT OF RIVERPARK		FACILITY NUMBER:	565850168
ADMINISTRATOR:	BERGAN, KIM		FACILITY TYPE:	740
ADDRESS:	901 TOWN CENTER DRIVE		TELEPHONE:	(805) 940-0390
CITY:	OXNARD	STATE: CA	ZIP CODE:	93036
CAPACITY:	140	CENSUS: 90	DATE:	05/04/2023
		UNANNOUNCED	TIME BEGAN:	11:52 AM
MET WITH:	Chris Andersen		TIME COMPLETED:	05:27 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Residents are being handled roughly

INVESTIGATION FINDINGS:

1
2
3
4
5
6
7
8
9
10
11
12
13

This report was originally issued on 11/29/2022. Due to formatting/pagination issues with the original report the findings for the above noted allegation are being reissued.

Licensing Program Analyst (LPA) Teresa Camara conducted a subsequent complaint visit to deliver findings for the above allegation. LPA met with administrator Chris Andersen and explained the reason for the visit.

On 06/27/2022, the Department received a complaint regarding an allegation of physical abuse. It was alleged that Resident #1 (R1) sustained repeated unexplained bruising on face and body as a result of being handled roughly by facility staff. The complaint was referred to the Community Care Licensing Investigations Branch (IB) and assigned to Investigator Jose Santana.

(continued on 9099-C, page 2)

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Jeralyn Ann Pfannenstiel	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Teresa Camara	TELEPHONE: 818-326-4019
LICENSING EVALUATOR SIGNATURE:	DATE: 05/04/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/04/2023

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 4

Control Number 29-AS-20220627090021

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: OAKMONT OF RIVERPARK	FACILITY NUMBER: 565850168
	VISIT DATE: 05/04/2023

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 9099, page 1)

On 07/01/2022, from 9:30am to 12:38pm, Licensing Program Analysts (LPAs) Teresa Camara and Elsie Campos conducted the initial complaint visit. LPAs Camara and Campos met with Memory Care Director (MCD) Amber Silverman, LVN and explained the reason for the visit. At approximately 09:35am, LPAs met with the MCD; at 10:05am, LPAs interviewed Resident #1 (R1); at 10:29am, LPAs met with Health Services

Director Sylvia Williams, LVN; at 10:55am, LPAs conducted an interview with a visitor. At approximately 10:15am, LPAs conducted a brief tour of memory care and the main lobby area of the facility. LPAs obtained pertinent documents at approximately 12:15pm. LPAs determined further investigation was needed prior to issuing findings.

On 07/20/2022, at approximately 2:00pm, Investigator Santana attempted to conduct an interview with R1, however, due to R1’s lack of orientation to person and place, was unable to conduct interview; on 07/22/2022, at approximately 3:30pm, conducted interviews with R1’s resident representative; on 07/26/2022, at approximately 4:00pm, with facility staff; on 08/17/2022, from approximately 12:35pm to 4:30pm, with facility staff; on 08/18/2022, at approximately 12:20pm with Hospice case manager; on 08/22/2022, from approximately 8:15am to 5:05pm, with facility staff and former facility agency staff; on 09/06/2022, from approximately 10:45am to 3:10pm, with former facility staff and Hospice RN; on 09/07/2022, from approximately 9:35am to 10:30pm, with Hospice manager and facility staff, at 3:30pm attempted interview with former facility staff #1 (S1) and again on 09/16/2022, but received no response; on 09/08/2022, from approximately 10:05am to 4:00pm, with facility staff, former facility staff, facility agency staff, hospice RN and MCD, at 12:00pm attempted interview with former facility agency staff #2 (S2) and on 09/14/2022 and 09/16/2022 attempted again to conduct interview with S2. Additionally, Investigator Santana requested and reviewed hospital medical records, hospice records, Ventura County Fire Department records, and facility file documents including incident reports, progress notes, facility staff schedule and photos of R1’s bruising. The Oxnard Police Department informed Investigator Santana there were no reports taken concerning R1. The Ventura County Long Term Care Ombudsman Program (LTCOP) were contacted and confirmed they were aware of the present allegation.

(continued on 9099-C, page 3)

SUPERVISOR'S NAME: Jeralyn Ann Pfannenstiel	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Teresa Camara	TELEPHONE: 818-326-4019
LICENSING EVALUATOR SIGNATURE:	DATE: 05/04/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/04/2023

LIC9099 (FAS) - (06/04)

Page: 2 of 4

Control Number 29-AS-20220627090021

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: OAKMONT OF RIVERPARK	FACILITY NUMBER: 565850168
	VISIT DATE: 05/04/2023

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 9099-C, page 2)

On 10/14/2021, R1 was admitted to the facility with a diagnosis of mild cognitive impairment and a history of being combative. R1 was able to ambulate with a walker but after having a series of falls in December 2021, R1 was no longer able to walk. R1 received physical therapy but was unable to regain the ability to walk and has since been wheelchair-bound. R1 was placed on hospice services as of 06/10/2022 and received a full bed rail on 06/13/2022. Information obtained through interviews found that the facility had been using the wooden backrest of a day bed to keep R1 from falling out of bed for approximately one month before R1 was placed on hospice care and ordered to use a full bed rail. This is a Personal Rights (restraints) violation and will be cited under a separate case management visit.

According to hospice and facility shift notes, a bruise was noted on R1’s eye on early morning of 06/10//22, stating “maybe struck bed”; a bruise on left eye was reported on 06/11/2022; a bruise on left eye was reported by the morning shift on 06/12/2022; hospice nurse saw bruising on right arm and hand on 06/17/2022; hospice nurse saw bruising to bilateral arms and legs on 06/22/2022; a red mark on center forehead was noted on the morning shift on 06/25/2022; staff found R1 lying in bed with a black eye on 06/25/22; and a bruise on forehead and eye noticed on the overnight shift into 06/26/2022.

During the course of the investigation, all staff members interviewed by investigator Santana denied knowing the cause of R1’s facial bruises that were discovered on the morning shift of 06/12/2022 and the overnight shift of 06/25/2022 into 06/26/2022. However, the most prevalent explanation is that R1’s face accidentally struck the wooden backrest of R1’s day bed, which the facility used as a restraint to keep R1 from falling while attempting to get out of bed, and the full bed rail that was delivered on 06/13/2022 per hospice orders.

(continued on 9099-C, page 4)

SUPERVISOR'S NAME: Jeralyn Ann Pfannenstiel	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Teresa Camara	TELEPHONE: 818-326-4019
LICENSING EVALUATOR SIGNATURE:	DATE: 05/04/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/04/2023

LIC9099 (FAS) - (06/04)

Page: 3 of 4

Control Number 29-AS-20220627090021

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: OAKMONT OF RIVERPARK	FACILITY NUMBER: 565850168
	VISIT DATE: 05/04/2023

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 9099-C, page 3)

The hospice nurses consulted had differing opinions on whether the bruises were consistent with striking the backrest/bedrail. Staff members denied witnessing physical abuse to R1 or being involved in physical abuse to R1. Investigator Santana attempted on several occasions and was unable to interview one particular former facility agency staff (S2) who was assigned as R1’s caregiver on at least one of the two evenings preceding the discovery of the injuries. This is the same caregiver believed to have documented a bruise on R1’s forehead on the morning of 06/25/2022 and may have knowledge as to its cause and possible linkage to the remaining bruising. Since the actual cause of injuries is not known, the department cannot determine whether they were intentional or accidental. The allegation that R1 sustained repeated unexplained bruising on face and body at the facility due to being handled roughly by staff is therefore deemed Unsubstantiated at this time.

Exit interview conducted and a copy of the report was emailed to the administrator.

SUPERVISOR'S NAME: Jeralyn Ann Pfannenstiel	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Teresa Camara	TELEPHONE: 818-326-4019
LICENSING EVALUATOR SIGNATURE:	DATE: 05/04/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/04/2023

LIC9099 (FAS) - (06/04)

Page: 4 of 4