565850169-1-26-2023-29-AS-DPEA-CP5QT4-20230217112632

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 565850169
Report Date: 01/26/2023
Date Signed: 01/26/2023 12:56:38 PM

Substantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 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
01/13/2023 and conducted by Evaluator Kelly Dulek

PUBLIC

COMPLAINT CONTROL NUMBER: 29-AS-20230113122859

FACILITY NAME:	OAKMONT OF CAMARILLO		FACILITY NUMBER:	565850169
ADMINISTRATOR:	FOERSCHNER, BRADLEE		FACILITY TYPE:	740
ADDRESS:	305 DAVENPORT STREET		TELEPHONE:	(805) 738-3600
CITY:	CAMARILLO	STATE: CA	ZIP CODE:	93012
CAPACITY:	150	CENSUS: 76	DATE:	01/26/2023
		UNANNOUNCED	TIME BEGAN:	10:50 AM
MET WITH:	Bradlee Foerschner		TIME COMPLETED:	01:00 PM

ALLEGATION(S):

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Resident was given the incorrect medication, resulting in hospitalization
Due to lack of care and supervision, resident sustained an injury
Facility is understaffed

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Kelly Dulek conducted a subsequent complaint inspection with the purpose of delivering findings for the allegations listed above. LPA arrived at the facility at 10:50AM and met with Executive Director (ED) Bradlee Foerschner. Entrance interview conducted.

During today’s visit, LPA toured the facility with Business Office Director Kailey Vanderwall. No health and safety hazards were observed during today’s visit. During an initial complaint inspection conducted on 01/19/2023, LPA interviewed ED at 12:15PM, staff at 12:58PM and 01:48PM, toured the facility with ED Foerschner at 01:19PM, reviewed medications at 01:31PM, and LPA reviewed and obtained copies of pertinent documents. Following the visit, LPA conducted a telephonic interview with Staff #1 (S1) and reviewed documents. The following was then determined:

Report Continued on LIC 9099-C

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Kristin Heffernan	TELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Kelly Dulek	TELEPHONE: (951) 836-3170
LICENSING EVALUATOR SIGNATURE:	DATE: 01/26/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/26/2023

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-20230113122859

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: OAKMONT OF CAMARILLO	FACILITY NUMBER: 565850169
	VISIT DATE: 01/26/2023

NARRATIVE

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Regarding the allegation “Resident was given the incorrect medication, resulting in hospitalization:”

Woodland Hills Regional Office received an incident report via e-fax on 11/03/2022, which informed CCL of a medication error involving Resident #1 (R1) on 10/28/2022. The incident report indicates R1 received the incorrect medication, R1’s vitals were low, and R1 was transported to the hospital for evaluation. Incident report indicates that all parties were informed of the incident and that the resident had returned to care at the facility. A second incident report involving R1 and a medication error was received at the Woodland Hills Regional Office via e-fax on 01/13/2023 indicating R1 was given the incorrect dosage of their medication. The medication error had been discovered on 01/09/2023, however R1 had been receiving the incorrect dosage of the medication since 12/19/2022, when R1’s physician had changed the orders for that particular medication. All medication staff were retrained on medication administration and the facility’s corporate office audited all residents’ medications as a result. During the visit on 01/19/2023, LPA Dulek reviewed R1’s medications with ED Foerschner and medication technician. Review of R1’s medications revealed that R1’s medications had changed again and that the new medications are not labeled properly, as the prescription numbers do not match the electronic MAR. Additionally, R1’s prescription Trazodone HCl indicates a quantity of 15 pills were provided, however there are only 14 pills in the bubble pack, and it is an unopened bubble pack. LPA and ED discussed the pharmacy errors and LPA suggested utilizing a paper MAR when the documentation provided by the pharmacy does not match the prescription labels. Also discussed was ultimately, the facility has the responsibility of ensuring all medications are properly labeled and administered. Based on medication review, record review, and interview, the allegation “resident was given the incorrect medication, resulting in hospitalization” is deemed SUBSTANTIATED at this time.

Regarding the allegation “Due to lack of care and supervision, resident sustained an injury:”

It was alleged that during the overnight shift on 01/06/2023 – 01/07/2023, that R1 was unaccounted for and that during that time, R1 sustained a hematoma to the forehead. Incident report was received in the Woodland Hills Regional Office via e-fax on 01/13/2023 indicating R1 was witnessed coming out of another resident’s apartment and was observed with an abrasion above R1’s right eyebrow. R1 was unable to recall what had happened or how R1 sustained the injury. Initially, interview with facility management indicated that R1 had last been checked during staff rounds around 02:30AM on 01/07/2023 and was found around 06:00AM with the injury. However, staff interview revealed that Staff #1 (S1) was working alone in the Memory Care unit during the overnight shift. During the overnight (10:00PM – 06:00AM) shift, S1 had not checked on Report Continued on LIC 9099-C

SUPERVISOR'S NAME: Kristin Heffernan	TELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Kelly Dulek	TELEPHONE: (951) 836-3170
LICENSING EVALUATOR SIGNATURE:	DATE: 01/26/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/26/2023

LIC9099 (FAS) - (06/04)

Page: 2 of 5

Control Number 29-AS-20230113122859

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: OAKMONT OF CAMARILLO	FACILITY NUMBER: 565850169
	VISIT DATE: 01/26/2023

NARRATIVE

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R1 at all. And since R1 does not take medications during the overnight shift, the medication technician working the entire building during the NOC shift had also not observed R1 during the shift. S1 had only been trained on 1 (one) of the 2 (two) care runs and therefore had only checked the residents in that care run during that shift. Interview also revealed that another resident was walking out of their room holding R1’s hand around 06:20AM and that is when Staff #2 (S2) discovered a large lump on R1’s head. R1’s Resident Assessment dated 11/21/2022 indicates “resident wakes up on some nights but is easily directed back to bed after ADL needs are met.” Resident Assessment also states, “resident wanders only within the common areas of the secured community....” Therefore, facility staff should have been aware that R1 does wander and requires assistance during the overnight shift. As thus, based on interview and record review, the allegation that “due to lack of care and supervision, resident sustained an injury” is deemed SUBSTANTIATED at this time.

Regarding the allegation “Facility is understaffed:”

It was alleged that during the overnight shift on 01/06/2023 – 01/07/2023, there was insufficient staffing to meet the needs of the residents. Interview revealed that typically there is one caregiver working in the Assisted Living unit and 2 caregivers working in the Memory Care unit, as well as one shared medication technician assisting with care needs in Assisted Living and medications throughout the building, totaling 4 care staff working the overnight shift in the facility. On the night of the incident involving R1, staff had called out of work, leaving one caregiver working in the Memory Care unit and a qualified member of the facility’s management team working as the shared medication technician. Interview revealed that there are at least 3 residents in the Memory Care unit that require a two person assist. The facility is continuing to work on hiring and training additional staff, but on the night of the incident involving R1, there was only one caregiver in the Memory Care unit to assist 23 residents. Therefore, based on interview, the allegation that “facility is understaffed” is deemed SUBSTANTIATED at this time.

The following deficiencies were observed (See LIC 809-D) and cited from the California Code of Regulations, Title 22 and/or California Health and Safety Code. Civil penalty issued in the amount of $500. Failure to correct the deficiencies may result in additional civil penalties.

Exit interview conducted. A copy of the report and appeal rights were provided.

SUPERVISOR'S NAME: Kristin Heffernan	TELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Kelly Dulek	TELEPHONE: (951) 836-3170
LICENSING EVALUATOR SIGNATURE:	DATE: 01/26/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/26/2023

LIC9099 (FAS) - (06/04)

Page: 3 of 5

Control Number 29-AS-20230113122859

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: OAKMONT OF CAMARILLO	FACILITY NUMBER: 565850169
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 01/26/2023

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 02/10/2023 Section Cited CCR 87465(a)(4)	1 2 3 4 5 6 7	87465 Incidental Medical and Dental Care (a) A plan for incidental medical and dental care shall be developed by each facility...compliance with the following: (4) The licensee shall assist residents with self-administered medications as needed This requirement is not met as evidenced by:	1 2 3 4 5 6 7	Executive Director indicated that all medication staff have been retrained on 01/17 and 01/18/2023, the company completed a medication audit on 01/12 and 01/13/2023, and this week, the pharmacy is on site each day to complete a medication audit in both medication rooms.
	8 9 10 11 12 13 14	Based on interview and record review, the facility staff gave another resident’s medications to R1 and when R1's physician changed R1's medication orders but the facility continued to administer the former dosage, which poses an immediate health risk to residents in care.	8 9 10 11 12 13 14	ED will submit to CCL a copy of the staff training, as well as results of the pharmacy audit and plan of action for correction, by POC due date.
Type A 02/03/2023 Section Cited CCR 87464(f)(1)	1 2 3 4 5 6 7	87464 Basic Services (f) Basic services shall at a minimum include: (1) Care and supervision as defined in Section 87101(c)(3) and Health and Safety Code section 1569.2(c) This requirement is not met as evidenced by:	1 2 3 4 5 6 7	ED agreed to retrain all overnight (NOC) staff on basic services, as well as care needs for all the residents in the Memory Care unit. Training will be completed and ED will provide proof of training to CCL, to include roster and topics covered by POC due date.
	8 9 10 11 12 13 14	Based on interview and record review, R1 has a known behavior of waking up at night and wandering and facility staff did not check on R1 during the overnight shift at all, and R1 sustained an injury of unknown origin, which poses an immediate health and safety risk to residents in care.	8 9 10 11 12 13 14

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	TELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Kelly Dulek	TELEPHONE: (951) 836-3170
LICENSING EVALUATOR SIGNATURE:	DATE: 01/26/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/26/2023

LIC9099 (FAS) - (06/04)

Page: 4 of 5

Control Number 29-AS-20230113122859

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: OAKMONT OF CAMARILLO	FACILITY NUMBER: 565850169
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 01/26/2023

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 02/03/2023 Section Cited CCR 87411(a)	1 2 3 4 5 6 7	87411(a) Personnel Requirements – General (a) Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs...provision of adequate services. This requirement is not met as evidenced by:	1 2 3 4 5 6 7	Executive Director agreed to send a copy of inservice training on attendance policies, a copy of the February staff schedule and will provide LPA with the date(s) for upcoming scheduled job fairs.
	8 9 10 11 12 13 14	Based on interview, there was only one caregiver staff working the NOC shift on 01/06/2023 – 01/07/2023 and did not check on all the residents in all care runs, which poses an immediate health and safety and personal rights risk to residents 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: Kristin Heffernan	TELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Kelly Dulek	TELEPHONE: (951) 836-3170
LICENSING EVALUATOR SIGNATURE:	DATE: 01/26/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/26/2023

LIC9099 (FAS) - (06/04)

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