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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 565850168
Report Date: 11/29/2021
Date Signed: 11/29/2021 04:31:50 PM

Document Has Been Signed on 11/29/2021 04:31 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, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME:OAKMONT OF RIVERPARKFACILITY NUMBER:
565850168
ADMINISTRATOR:BERGAN, KIMFACILITY TYPE:
740
ADDRESS:901 TOWN CENTER DRIVETELEPHONE:
(805) 940-0390
CITY:OXNARDSTATE: CAZIP CODE:
93036
CAPACITY: 140CENSUS: 87DATE:
11/29/2021
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Kim BerganTIME COMPLETED:
04:31 PM
NARRATIVE
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Licensing Program Analyst (LPA) JoAnn Rosales conducted an Case Management visit at the above facility to investigate an incident that occurred on 11/19/21. LPA met with Administrator Kim Bergan.

On 11/23/21 LPA spoke with the Administrator regarding an incident report received for resident #1 (R1) indicating that R1 eloped from the facility on 11/19/21. Administrator stated that R1 followed another residents family out of the facility and was found a block away from the facility. Staff picked up R1 and they returned to the facility. R1 did not sustain any injuries. Administrator stated that based on R1's physicians report R1 is not able to leave the facility unassisted. Administrator stated that a wanderguard was placed on R1 and the memory care egress door code was changed.

During today’s visit LPA toured the facility with the Administrator, review resident records and obtained copies of pertinent documents. During the facility tour at 11:37 am with the Administrator LPA observed laundry detergent in the 2nd floor laundry room accessible to residents. Administrator stated that a resident must have left the laundry detergent in the laundry room. LPA reviewed R1's records on 11/29/21 starting at 12:18 pm which revealed that R1 is not able to leave the facility unassisted. R1's care plan has been updated to reflect R1's wandering behavior.

Administrator stated that R1's physician and responsible person were notified of the incident. Administrator stated that the memory care staff have been in-serviced regarding safety and elopement protocols. Administrator stated that they will be notifying all family members in writing tomorrow letting them know to make sure that no one is following them out of the memory care area. Based on the information obtained during the investigation staff failed to supervise R1 on 11/19/21 as R1 eloped from the facility.

Pursuant to Title 22 Division 6 Chapter 8 of the CA Code of Regulations, the following deficiencies were cited (refer to LIC 809-D):


Exit interview conducted, todays reports were reviewed and emailed to the Administrator.
SUPERVISORS NAME: Kristin Heffernan
LICENSING EVALUATOR NAME: Joann Rosales
LICENSING EVALUATOR SIGNATURE: DATE: 11/29/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/29/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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Document Has Been Signed on 11/29/2021 04:31 PM - It Cannot Be Edited


Created By: Joann Rosales On 11/29/2021 at 12:50 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

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

FACILITY NAME: OAKMONT OF RIVERPARK
FACILITY NUMBER: 565850168

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/29/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
11/30/2021
Section Cited
CCR
87464(f)(1)(c)

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87464 Basic services (f)(1)(c) "Care and supervision" means the facility assumes responsibility for, or provides or promises to provide in the future, ongoing assistance with activities of daily living without which the resident’s physical health, mental health, safety, or welfare would be endangered.
This requirement is not met as evidenced by:
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Administrator stated that a wanderguard was placed on R1 and family members will be notified in writing tomorrow not to let anyone follow them out of the memory care area. Administrator stated that they will provide documentation of staff training regarding safety and elopement protocols to CCL by 12/3/21.
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Based on interviews and record review, the licensee did not comply with the section cited above as R1 left the facility unassisted which poses an immediate health and safety risk to persons in care.
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Type A
11/30/2021
Section Cited
CCR87705(f)(2)

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87705 Care of Persons with Dementia (f)(2) The following shall be stored inaccessible to residents with dementia: Over-the-counter medication, nutritional supplements or vitamins, alcohol, cigarettes, and toxic substances such as certain plants, gardening supplies, cleaning supplies and disinfectants.
This requirement is not met as evidenced by:
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Administrator placed laundry detergent in a locked laundry room during facility visit. Administrator stated that they will notify all residents that they cannot leave laundry detergent and supplies in the laundry room.
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Based on LPA's observations, the licensee did not comply with the section cited above as laundry detergent was accessible to residents which poses 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.
SUPERVISOR'S NAME:Kristin Heffernan
LICENSING EVALUATOR NAME:Joann Rosales
LICENSING EVALUATOR SIGNATURE:
DATE: 11/29/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/29/2021


LIC809 (FAS) - (06/04)
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