565850168-9-16-2026-29-AS-KLOZ-DYE2PX-20260929173503

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 565850168
Report Date: 09/16/2026
Date Signed: 09/16/2026 10:54:46 AM

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
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:	09/16/2026
		UNANNOUNCED	TIME BEGAN:	09:50 AM
MET WITH:	Erik Bleitz		TIME COMPLETED:	11:00 AM

ALLEGATION(S):

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Staff left resident in soiled diapers for extended period of time
Staff are not checking on residents in a timely manner

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA), Esther Cortez conducted an unannounced subseqnent complaint visit to deliver findings for the the above allegations. Upon arrival, LPA met with Executive Director (ED), Erik Bleitz 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.

Substantiated

Estimated Days of Completion:

SUPERVISORS NAME: Kasandra Lopez
LICENSING EVALUATOR NAME: Esther Cortez
LICENSING EVALUATOR SIGNATURE:	DATE: 09/16/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/16/2026

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: 09/16/2026

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. On 06/30/26, the LPA interviewed the Health Service Director, attempted to contact a former staff, and conducted a file review.

On the allegations “Staff left resident in soiled diapers for extended period of time and Staff are not checking on residents in a timely manner”; it is the concern of the Reporting Party (RP) that Resident 1 (R1) was being left in soiled diapers and clothing for long periods of time to the point that R1 was soaked and their private area was pink. It was further alleged that Resident 3 (R3) was constantly heard yelling for help throughout the day and night and staff were not assisting. The LPA interviewed nine (9) facility staff members regarding care delivery and supervision. Staff members interviewed 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. However, three (3) out of six (6) staff members who provide direct care to the residents revealed that they found residents left soiled for an extended period or residents have had to wait an extended amount of time for assistance. One staff revealed that they had seen residents being left soiled for an extended period and could identify this by the strong odor, also revealed that it routinely takes approximately 20 minutes to change residents and they could benefit from having more staff. Another staff revealed that residents are checked and changed every 2 hours unless care plan requires hourly checks, however they have personally witnessed it taking up to 30 minutes for residents to be changed. A third staff member revealed that when the morning shift arrives, they have found residents heavily soiled and continued to state that they believe there have been times where they believe residents were left soiled for an extended period based on the strong odor and the fact that urine had transferred on the bed linens. They also revealed that R1’s wife disliked staff entering the room and would attempt to change the resident herself against staff instructions. Additionally, two (2) other staff members revealed that the facility needs more help (an extra caregiver), stating that the quality of care is being actively impacted by the lack of staff. It was reported that if a resident calls for assistance, staff cannot immediately respond because facility floor coverage prevents them from leaving their designated areas until another staff member covers the floor.

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

SUPERVISORS NAME: Kasandra Lopez
LICENSING EVALUATOR NAME: Esther Cortez
LICENSING EVALUATOR SIGNATURE:	DATE: 09/16/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/16/2026

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: 09/16/2026

NARRATIVE

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Interviews with two (2) witnesses who visit residents at the facility revealed that while one witness reported witnessing staff checking on residents on a regular basis the other witness revealed that the resident they visited had developed a severe diaper rash which they believed was caused by being left in soiled briefs. Furthermore, a review of a pendant history log from 09/09/25 to 09/27/25 revealed that 56 pendant calls from six (6) different residents, including R1, went unanswered. The history log explicitly indicated, “Response required but not received as of … This alert was never responded to”. Executive Director Erik Bleitz informed the LPA that previous ED Kailey Vanderwall had noted that either R1 or their spouse would not allow the staff to clear the calls, and provided documentation consisting of eight (8) pages detailing 14 separate instances where the log indicated the call went unanswered but noted that staff spoke to the resident and attempted to clear the calls. 42 pendant calls that were noted being left unanswered did not have documentation of them being answered. Additionally, 16 pendant calls took over 20 minutes for a response; of those 16 calls, 4 took over 30 minutes, and 1 took over 40 minutes. Based on the information obtained, the allegations are deemed Substantiated at this time.

Pursuant to Title 22, California Code of Regulations, the following deficiency is cited (refer to LIC9099-D). A copy of this report and appeal rights was provided.

SUPERVISORS NAME: Kasandra Lopez
LICENSING EVALUATOR NAME: Esther Cortez
LICENSING EVALUATOR SIGNATURE:	DATE: 09/16/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/16/2026

LIC9099 (FAS) - (06/04)

Page: 3 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
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 09/16/2026

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 09/17/2026 Section Cited CCR 87468.2(a)(4)	1 2 3 4 5 6 7	(a)…residents…shall have all of the following personal rights: (4) To care, supervision, and services that meet their individual needs and are delivered by staff that are sufficient in numbers, qualifications, and competency to meet their needs. This requirement was not met as evidence by:	1 2 3 4 5 6 7	ED agreed to submit a Plan of Action, documenting how the facility will ensure residents are being changed and checked on in a timely manner, which may include additonal staff and trainings. Plan will be subitted no later than 09/17/26.
	8 9 10 11 12 13 14	Based on interviews and record review staff admitted residents were left soiled for extended periods and pendant calls were left unanswered or took 20 to 40 minutes for residents to receive assistance which poses an immediate health and safety risk to persons in care.	8 9 10 11 12 13 14
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

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: Kasandra Lopez
LICENSING EVALUATOR NAME: Esther Cortez
LICENSING EVALUATOR SIGNATURE:	DATE: 09/16/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/16/2026

LIC9099 (FAS) - (06/04)

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