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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 565850168
Report Date: 12/23/2024
Date Signed: 12/23/2024 12:51:00 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS N.ASC, 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
12/17/2024 and conducted by Evaluator Erica Mosley
COMPLAINT CONTROL NUMBER: 29-AS-20241217142256
FACILITY NAME:OAKMONT OF RIVERPARKFACILITY NUMBER:
565850168
ADMINISTRATOR:KAILEY VANDERWALLFACILITY TYPE:
740
ADDRESS:901 TOWN CENTER DRIVETELEPHONE:
(805) 940-0390
CITY:OXNARDSTATE: CAZIP CODE:
93036
CAPACITY:140CENSUS: 85DATE:
12/23/2024
UNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:KAILEY VANDERWALL- Executive DirectorTIME COMPLETED:
12:55 PM
ALLEGATION(S):
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Resident was left in an unkempt room overnight.
Resident had access to an item that could pose a danger.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA), Erica Mosley conducted an unannounced subsequent complaint visit to deliver findings the above allegations. Upon arrival, LPA met with Executive Director Kailey Vanderwall and explained the reason for the visit. On todays visit LPA Mosley conducted a physical plant tour at 10:35 a.m. to ensure there are no immediate health and safety hazards and facility is in compliance with Title 22 Regulations.

On 12/17/2024, LPA Esther Cortez between 03:15 p.m. and 5:00 p.m., interviewed the ED, MC Director, two (2) staff, and obtained copies of resident records and other pertinent documents relevant to the investigation. On 12/19/2024, between 08:30 a.m. and 3:00 p.m., LPA Cortez conducted a file review and interviewed six (6) staff.

Report continued on LIC9099-C....
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Kasandra Lopez
LICENSING EVALUATOR NAME: Erica Mosley
LICENSING EVALUATOR SIGNATURE:

DATE: 12/23/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/23/2024
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 5
Control Number 29-AS-20241217142256
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME: OAKMONT OF RIVERPARK
FACILITY NUMBER: 565850168
VISIT DATE: 12/23/2024
NARRATIVE
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Report continued from LIC9099....

On the allegations, “Resident was left in an unkempt room overnight and Resident had access to an item that could pose a danger,”; it is the concern of the reporting party (RP) that on 10/15/2024, Resident 1 (R1) in Memory Care was able to get a hold of a fire extinguisher, pulled the pin, and made a mess all over their room with the fire extinguisher powder. RP further reported that they did not know if the powder was toxic, and R1 was left in their room with all the powder overnight until it was cleaned on 10/16/2024. Lastly, the RP reported that R1 grabbed the fire extinguisher again and staff keep leaving it accessible.

Interviews conducted with staff revealed that six (6) out of nine (9) staff had knowledge of R1’s incident with the fire extinguisher. Staff 1 (S1) revealed that they do not remember the exact date but does recall that a few months ago while working their NOC shift, during their second rounds of checking on the residents between 1:00 a.m. and 3:00 a.m. they found that R1 had taken a fire extinguisher to their room and sprayed the whole room. They did not know if was dangerous to inhale and the MedTech present called the Memory Care Director (MCD) and advised them of the incident. The MCD called them back and informed them that they had spoken to the Director of Maintenance and was told that it was okay to leave R1 in the room. S1 revealed that R1 was then left in their room. When asked regarding who and when was the room cleaned, they responded that they put a work order for the next day and the room was cleaned until the next day by the maintenance staff or the housekeeper. Staff 2 (S2) revealed that they were informed of the incident the morning of the incident, went to clean the room, observed the resident in the room, the powder was all over the room, and they cleaned it with a vacuum. Staff 3 (S3) revealed that after S2 cleaned the room they went and cleaned the stains on the carpet. Furthermore, staff revealed that grabbing the fire extinguisher was a known behavior of R1, staff re-direct R1 anytime he grabs a fire extinguisher, and the fire extinguishers are accessible to the residents. On 12/17/2024, the LPA observed the fire extinguishers stored in unlocked, white fire extinguisher cabinets with a glass cover, accessible to the residents in care.

Report continued on LIC9099-C....

SUPERVISORS NAME: Kasandra Lopez
LICENSING EVALUATOR NAME: Erica Mosley
LICENSING EVALUATOR SIGNATURE:

DATE: 12/23/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/23/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 29-AS-20241217142256
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME: OAKMONT OF RIVERPARK
FACILITY NUMBER: 565850168
VISIT DATE: 12/23/2024
NARRATIVE
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Report continued from LIC9099-C....

The LPA obtained twelve (12) photos, that were reported to be of R1’s room and bathroom with the fire extinguisher powder. Photos #1 and #2 (P1, P2) show a fire extinguisher on a carpeted floor in a dark room. The carpet appears to have a large amount of visible yellow powder near the extinguisher. The texture of the carpet is clearly visible, you can see footprints on top of the powder. The corner of a bed is seen in the lower right corner of the image in P1, and the bottom of a person’s foot is seen on top of the bed. P3 shows a lighted bedroom with a bed, two side tables, and a lamp. The bed has pillows and a blanket, and there is a dark blanket draped over the foot of the bed. A recliner chair is visible in the background. The carpeted floor in the foreground appears to have a large amount of powder on the carpet, the powder is scattered and spread unevenly over the carpet. Footprints or patterns are visible. Near the left side foot of the bed appears to have a heavier concentration of the fire extinguisher powder compared to the rest of the carpet. P4-P9 show the powder throughout the room on the hallway carpet, bathroom floor, over the furniture and blankets on the bed. All photos have the date stamp of 10/16/2024.

Regarding the allegations, “Resident was left in an unkempt room overnight and Resident had access to an item that could pose a danger,” information obtained throughout the investigation revealed that on 10/16/2024, R1 had access to a fire extinguisher despite the fire extinguisher cabinets having locking mechanisms and staff knowing that grabbing the fire extinguisher was a known behavior of R1. R1 pulled the pin and set it off in their room. Additionally, staff admitted to leaving R1 in the room overnight without the fire extinguisher powder being cleaned up until the morning staff arrived. Furthermore, photos revealed that R1’s whole room was covered with fire extinguisher powder. Based on the above information gathered, there is sufficient evidence to support the allegation and that a violation occurred; therefore, the above allegations are deemed Substantiated at this time.

The following deficiencies were cited from the CA Code of Regulations, Title 22. Failure to correct the deficiencies may result in civil penalties. Exit interview held, appeal rights and report copy provided.

SUPERVISORS NAME: Kasandra Lopez
LICENSING EVALUATOR NAME: Erica Mosley
LICENSING EVALUATOR SIGNATURE:

DATE: 12/23/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/23/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 5
Control Number 29-AS-20241217142256
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: OAKMONT OF RIVERPARK
FACILITY NUMBER: 565850168
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/23/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Request Denied
Type A
12/24/2024
Section Cited
CCR
87303(a)(1)
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87303(a)(1) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. (1) Floor surfaces in bath, laundry and kitchen areas shall be maintained in a clean, sanitary, and odorless condition. This requirement is not met as evidenced by:
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ED agrees to submit plan on how they will ensure resident rooms are maintained in a clean and sanitary condition including during NOC shifts. Submit to CCL by 12/24/24.
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Based on photos and interviews, the licensee did not comply with the section cited above as R1 was left in their room overnight with fire-extinguisher powder all over the room which posed an immediate health and safety risk to persons in care.
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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.
SUPERVISORS NAME: Kasandra Lopez
LICENSING EVALUATOR NAME: Erica Mosley
LICENSING EVALUATOR SIGNATURE:

DATE: 12/23/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/23/2024
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 29-AS-20241217142256
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: OAKMONT OF RIVERPARK
FACILITY NUMBER: 565850168
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/23/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Request Denied
Type B
12/27/2024
Section Cited
CCR
87705(f)(1)
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87705(f)(1) Care of Persons with Dementia (f) The following shall be stored inaccessible to residents with dementia: (1) Knives, matches, firearms, tools and other items that could constitute a danger to the resident(s). This requirement is not met as evidenced by:
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ED agrees to submit a plan on how they will ensure items that could constitute a danger to the resident(s) will be stored inaccessible to residents with dementia.
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Based on interviews and observation, the licensee did not comply with the section cited above, as R1 had access to fire extinguisher, despite staff knowing that grabbing the fire extinguisher was a known behavior of R1, which posed a potential safety risk to persons in care.
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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.
SUPERVISORS NAME: Kasandra Lopez
LICENSING EVALUATOR NAME: Erica Mosley
LICENSING EVALUATOR SIGNATURE:

DATE: 12/23/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/23/2024
LIC9099 (FAS) - (06/04)
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