565850169-10-18-2023-29-AS-KDUK-CWQTW2-20231018150450

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 565850169
Report Date: 10/18/2023
Date Signed: 10/18/2023 03:05:12 PM

Document Has Been Signed on 10/18/2023 03:05 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 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: 77	DATE:	10/18/2023
TYPE OF VISIT:	Case Management - Incident	UNANNOUNCED	TIME BEGAN:	01:30 PM
MET WITH:	Bradlee Foerschner		TIME COMPLETED:	03:10 PM

NARRATIVE

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Licensing Program Analysts (LPAs) Teresa Camara and Kelly Dulek conducted an unannounced Case Management – Incident visit for the purpose of following up on three (3) self-reported incidents that occurred on 09/18/2023, 10/01/2023, and 10/11/2023. LPAs met with Executive Director Bradlee Foerschner. LPAs explained the reason for today's visit.

Previously, on 09/19/2023 an Unusual Incident/Injury Report was received via e-fax at the Woodland Hills Regional Office. LPA reviewed the document, which indicates that Resident #1 (R1) left the community unsupervised and was found a block away. R1 resides in Assisted Living, however has a dementia diagnosis and is unable to leave the facility unassisted. On 09/22/2023, LPA conducted an initial case management - incident visit related to R1 leaving the community unsupervised. During that visit, LPA Dulek, along with Business Office Director toured the facility at 08:52AM, interviewed staff between 09:33AM to 10:30AM as well as at 12:31PM, and LPA obtained copies of pertinent documents. Additionally, LPA, along with Health Services Director and Business Office Director tested the Wanderguard alert beginning at 11:11AM, and LPA interviewed residents from 11:44AM to 12:13PM.

On 10/02/2023, ED had called and left a voicemail message for the LPA indicating Resident #2 (R2) who resides in Traditions had been found outside about a block away from the facility on 10/01/2023. R2 does have a diagnosis of dementia and is unable to leave the facility unassisted. During a case management - incident visit conducted on 10/05/2023, LPA interviewed ED related to this incident as well as the previous incident involving R1, LPA along with ED toured the facility at 12:45PM, all delayed egress points were tested, and LPA obtained copies of documents pertinent to the incident.

On 10/12/2023, LPA Dulek received a telephone call from ED indicating that on 10/11/2023 around 03:00PM, R2 was found outside the facility and had fallen in front of a neighboring home.

Report Continued on LIC 809-C

SUPERVISOR'S NAME: Kristin Heffernan	TELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Kelly Dulek	TELEPHONE: (951) 836-3170
LICENSING EVALUATOR SIGNATURE:	DATE: 10/18/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/18/2023

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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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
	VISIT DATE: 10/18/2023

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During today's visit, both LPAs conducted interviews with staff and residents from 01:29PM to 02:40PM. LPAs obtained a copy of written incident report for the 10/01/2023 incident. ED indicated that following the latest incident, R2 has been given a Wanderguard bracelet for additional safety.

Pursuant to Title 22 CA Code of Regulations, the following deficiency was cited (refer to LIC 809-D). Executive Director was informed that failure to correct the deficiency may result in 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: 10/18/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/18/2023

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 10/18/2023 03:05 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: 10/18/2023

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 10/20/2023 Section Cited CCR 87464(f)(1)(c)	1 2 3 4 5 6 7	87464 Basic services (f)(1)(c) "Care and supervision" means the facility assumes responsibility for...ongoing assistance with activities of daily living without which the resident’s physical health, mental health, safety, or welfare would be endangered. This requirement is not met as evidenced by:	1 2 3 4 5 6 7	ED indicated R1 moved out of the facility. Following the incidents, R2 has 1:1 supervision, been given a Wanderguard bracelet. ED will send a letter to all residents, families, and outside vendors reminding of facility policies related to facility safety and security. A copy of the letter will be submitted
	8 9 10 11 12 13 14	Based on interviews and record review, the licensee did not comply with the section cited above as R1 left the facility unassisted and R2 left the facility unassisted twice, which poses an immediate health and safety risk to persons in care.	8 9 10 11 12 13 14	to CCL by POC due date.
	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: 10/18/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/18/2023

LIC809 (FAS) - (06/04)

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