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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 565850168
Report Date: 11/29/2022
Date Signed: 11/29/2022 03:23:37 PM

Document Has Been Signed on 11/29/2022 03:23 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:JASON RUSSOFACILITY TYPE:
740
ADDRESS:901 TOWN CENTER DRIVETELEPHONE:
(805) 940-0390
CITY:OXNARDSTATE: CAZIP CODE:
93036
CAPACITY: 140CENSUS: 86DATE:
11/29/2022
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
01:50 PM
MET WITH:Chris AndersenTIME COMPLETED:
03:50 PM
NARRATIVE
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Licensing Program Analyst (LPA) Teresa Camara conducted a case management - deficiencies visit due to deficiencies discovered over the course of the investigation of complaint control number 29-AS-20220627090021. LPA met with administrator Chris Andersen and explained the reason for the visit.

During the course of his investigation, Community Care Licensing Investigations Branch (IB) Investigator Jose Santana, discovered Resident #1 (R1) had been restrained in bed by a wooden daybed backrest used as a bed rail for approximately one month prior to R1 being placed on hospice 6/10/2022 and receiving an order for full bed rails. R1 sustained unexplained bruising on their face and body. Investigator Santana was unable to determine the cause of the multiple bruises sustained by R1 but a common assumption by staff was that the bruising was caused by the wooden backrest being used as a bed rail.

Pursuant to Title 22, California Code of Regulations, the following deficiency is cited (refer to LIC 809-D).

Exit interview conducted, appeal rights discussed, and a copy of this report issued.
SUPERVISORS NAME: Jeralyn Ann Pfannenstiel
LICENSING EVALUATOR NAME: Teresa Camara
LICENSING EVALUATOR SIGNATURE: DATE: 11/29/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/29/2022
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 11/29/2022 03:23 PM - It Cannot Be Edited


Created By: Teresa Camara On 11/29/2022 at 01:26 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: 11/29/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
12/02/2022
Section Cited
CCR
87608(a)(5)(B)

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87608 Postural Supports (a) Based on the individual's preadmission appraisal, and subsequent changes to that appraisal, the facility shall provide assistance and care for the resident in those activities of daily living which the resident is unable to do for himself/herself. Postural supports may be used under the following conditions.(5)Under no
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 Licensee will submit a written action plan regarding proper use of bed rails and other postural supports to CCL by 12/02/2022.
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circumstances shall postural supports include tying, depriving, or limiting the use of a resident's hands or feet.(B) Bed rails that extend the entire length of the bed are prohibited except for residents who are currently receiving hospice care and have a hospice care plan that specifies the need for full bed rails.
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Based on interviews and records review, the licensee did not comply with the section cited above. Staff used a full length wooden backrest in place of full bed rails prior to R1 being placed on hospice which resulted in R1 sustaining multiple bruises, which posed an immediate health and safety risk to residents 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:Jeralyn Ann Pfannenstiel
LICENSING EVALUATOR NAME:Teresa Camara
LICENSING EVALUATOR SIGNATURE:
DATE: 11/29/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/29/2022


LIC809 (FAS) - (06/04)
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