565850168-7-23-2026-29-AS-KLOZ-DYE2PY-20260929173503

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 565850168
Report Date: 07/23/2026
Date Signed: 07/23/2026 04:49:01 PM

Unsubstantiated

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
09/18/2025 and conducted by Evaluator Esther Cortez

COMPLAINT CONTROL NUMBER: 29-AS-20250918145410

FACILITY NAME:	OAKMONT OF RIVERPARK		FACILITY NUMBER:	565850168
ADMINISTRATOR:	KAILEY VANDERWALL		FACILITY TYPE:	740
ADDRESS:	901 TOWN CENTER DRIVE		TELEPHONE:	(805) 940-0390
CITY:	OXNARD	STATE: CA	ZIP CODE:	93036
CAPACITY:	140	CENSUS: 90	DATE:	07/23/2026
		UNANNOUNCED	TIME BEGAN:	09:30 AM
MET WITH:	Erik Bleitz		TIME COMPLETED:	04:45 PM

ALLEGATION(S):

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Resident fell several times due to staff neglect resulting in injury

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA), Esther Cortez conducted an unannounced subseqnent complaint visit for the above allegations. Upon arrival, LPA met with staff and exaplained the reason for the visit. The Executive Director (ED), Erik Bleitz arrived at 11:00 a.m. and was explained the reason for the visit. Entrance interview conducted.

On 09/23/25, between 10:00 a.m. and 3:00 p.m., the LPA interviewed the Executive Director, two (2) staff, three (3) residents, conducted observations, a file review, tested two residents emergency call button in their restroom and obtained copies of resident records and other pertinent documents relevant to the investigation. On 12/23/25, between 9:40 a.m. and 4:30 p.m., the LPA interviewed the Executive Director, four (4) staff, one (1) witness, conducted a resident file review, and obtained copies of resident records and other pertinent documents relevant to the investigation.

Report will continue on LIC9099-C, 2nd page.

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Kasandra Lopez
LICENSING EVALUATOR NAME: Esther Cortez
LICENSING EVALUATOR SIGNATURE:	DATE: 07/23/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/23/2026

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-20250918145410

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: 07/23/2026

NARRATIVE

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On 07/20/26, the LPA interviewed, the ED, three (3) staff, one (1) witness, two (2) residents, attempted to interview two (2) additional residents, conducted a file review and obtained copies of resident records and other pertinent documents relevant to the investigation. During today's inspection the LPA interviewed the Health Service Director, attempted to contact a former staff, and conducted a file review.

On the allegation, “Resident fell several times due to staff neglect resulting in injury,” it is the concern of the Reporting Party (RP) that Resident #1 (R1) has fallen multiple times at the facility and is a fall risk. Interview with the RP revealed that the resident did not sustain any injuries during the falls.

According to the facility file documents reviewed, R1 was admitted to the facility on 8/22/25. The initial assessment on the Individualized Service Plan (ISP), dated 8/24/25, under fall management noted that R1 had fallen within the past year and required a fall management program. The ISP outlined tasks to minimize environmental fall risk factors, ensure the apartment remained well-lit and free from clutter, and ensure essential items remained within R1's reach. The ISP indicated that R1 did not require status (hourly) checks, while facility charting notes directed staff to perform bi-hourly (2-hour) checks and identified R1 as a 2-person assist.

Review of facility charting notes dated 9/11/25, revealed that the previous Memory Care Director (MCD) conducted a care conference with R1’s daughter regarding ongoing fall concerns. The MCD informed the family that the facility could not completely prevent falls but would implement safety interventions. During this conference, a fall detection pendant was put in place for R1, and the MCD provided outside agency resources to the family to secure 1:1 companion care for R1 during night shifts.

Facility charting notes from the time of admission to the submission of the complaint documented that R1 sustained two (2) falls, where R1 was found on the floor. One of these falls occurred on 9/9/25. An incident report dated 9/10/25, documented that R1 was transferred to the hospital due to a blood clot and was subsequently diagnosed with a Urinary Tract Infection (UTI). Interviews with facility staff members indicated a recollection of multiple falls, ranging from four falls to a "handful" of falls.

Report will continue on LIC9099-C, 3rd page.

SUPERVISORS NAME: Kasandra Lopez
LICENSING EVALUATOR NAME: Esther Cortez
LICENSING EVALUATOR SIGNATURE:	DATE: 07/23/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/23/2026

LIC9099 (FAS) - (06/04)

Page: 2 of 4

Control Number 29-AS-20250918145410

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: 07/23/2026

NARRATIVE

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The Licensing Program Analyst (LPA) interviewed nine (9) facility staff members regarding care delivery and supervision. Six (6) out of nine (9) staff members consistently corroborated that R1 was checked every two hours or as needed, which directly aligned with the monitoring protocol established in R1's charting notes. One staff member and the current Memory Care Director noted that the general facility protocol for fall-risk residents is hourly checks; however, R1's specific care directives mandated 2-hour intervals. The Health Service Director confirmed that fall-risk residents are checked every two hours, that R1 was explicitly scheduled for two-hour checks, and that R1's fall patterns did not warrant an escalation to hourly status checks

Five (5) staff interviews revealed that some of R1's falls occurred when R1's wife was present in the room. Two staff members stated that the wife frequently removed R1's fall detection pendant and attempted to transfer R1 to the bathroom independently, causing R1 to become weak and slide to the floor without staff knowledge or the opportunity for staff intervention.

One (1) out of nine staff members stated that they had found R1 on the floor and R1 told them a staff member had checked on R1 and did not help them up. This statement was not substantiated by any other staff interviews, internal facility charting, or physical evidence. The remaining eight (8) staff members provided no evidence of physical or supervisory neglect. Furthermore, the RP revealed during an interview that R1 did not sustain any injuries during the falls.

Based on the evidence gathered during the investigation, the facility implemented a fall detection pendant and discussed 1:1 care options with the family. Staff interviews revealed R1 was checked on every two hours as the documented 2-hour monitoring protocol warranted. While R1 did experience multiple falls, there is no evidence to confirm that the falls were the result of staff neglect, nor is there evidence that R1 sustained physical injuries. Therefore, the allegation, “Resident fell several times due to staff neglect resulting in injury,” is UNSUBSTANTIATED at this time.

Exit interview conducted. Today's report was reviewed and provided to the Executive Director.

SUPERVISORS NAME: Kasandra Lopez
LICENSING EVALUATOR NAME: Esther Cortez
LICENSING EVALUATOR SIGNATURE:	DATE: 07/23/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/23/2026

LIC9099 (FAS) - (06/04)

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