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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 565850169
Report Date: 03/22/2023
Date Signed: 03/22/2023 06:17:50 PM


Document Has Been Signed on 03/22/2023 06:17 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 CAMARILLOFACILITY NUMBER:
565850169
ADMINISTRATOR:FOERSCHNER, BRADLEEFACILITY TYPE:
740
ADDRESS:305 DAVENPORT STREETTELEPHONE:
(805) 738-3600
CITY:CAMARILLOSTATE: CAZIP CODE:
93012
CAPACITY:150CENSUS: 77DATE:
03/22/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Bradlee FoerschnerTIME COMPLETED:
06:17 PM
NARRATIVE
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Licensing Program Analyst (LPA) Kelly Dulek conducted a case management-deficiencies visit at the facility today. The LPA arrived at 11:00AM and met with Executive Director (ED) Bradlee Foerschner. Entrance interview conducted.

During today’s visit, LPA conducted a medication review with ED and the Medication Technician at 12:52PM. During the medication review, it was discovered that Resident #1 (R1)'s prescription Atorvastatin 40 mg was labeled as started 11/29/2022, originally contained 100 pills, but ED counted more than 100 pills in the bottle. MAR indicated this medication has been administered daily in March 2023. ED counted medications and verified that two (2) additional medications did not contain the amount indicated the bottles should contain, without documentation of exceptions. Medications for Resident #2 (R2) were also reviewed. R2's Atorvastatin 10mg was opened on 03/03/2023 and originally contained 30 doses. 21 doses remain, although 20 days have elapsed since 03/03/2023 and therefore only 10 doses should remain. R2's Trazodone 50mg was opened 03/02/2023 and originally contained 30 doses. 9 doses remain, although 10 should remain based on days elapsed since the date the medication was opened.

Pursuant to Title 22 CA Code of Regulations, the following deficiency was cited (refer to LIC 809-D). As this is a repeat violation, a civil penalty was issued in the amount of $250. Exit interview conducted. A copy of the report and appeal rights were provided.
SUPERVISOR'S NAME: Kristin HeffernanTELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Kelly DulekTELEPHONE: (951) 836-3170
LICENSING EVALUATOR SIGNATURE:
DATE: 03/22/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/22/2023
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 03/22/2023 06:17 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 03/22/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
03/30/2023
Section Cited

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87465 (a)A plan for incidental medical and dental care shall be developed by each facility....by compliance with the following: (4) The licensee shall assist residents with self-administered medications as needed.
This requirement is not met as evidenced by:
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Administrator agreed to communicate with LPA by close of business on POC due date a comprehensive plan of correction to include Human Resources, corporate resources, and additional training/audits.
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Based on record review, the licensee did not comply with the above cited section, as medications for 2 of 2 residents reviewed contained an inaccurate amount of doses, which poses 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: Kristin HeffernanTELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Kelly DulekTELEPHONE: (951) 836-3170
LICENSING EVALUATOR SIGNATURE:
DATE: 03/22/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/22/2023
LIC809 (FAS) - (06/04)
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