565850169-12-7-2023-29-AS-KHEN-CYX2QN-20231227163612

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 565850169
Report Date: 12/07/2023
Date Signed: 12/07/2023 03:25:03 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
03/23/2022 and conducted by Evaluator Kelly Dulek

PUBLIC

COMPLAINT CONTROL NUMBER: 29-AS-20220323121610

FACILITY NAME:	OAKMONT OF CAMARILLO		FACILITY NUMBER:	565850169
ADMINISTRATOR:	BERARD, MARTHA		FACILITY TYPE:	740
ADDRESS:	305 DAVENPORT STREET		TELEPHONE:	(805) 738-3600
CITY:	CAMARILLO	STATE: CA	ZIP CODE:	93012
CAPACITY:	150	CENSUS: 84	DATE:	12/07/2023
		UNANNOUNCED	TIME BEGAN:	09:34 AM
MET WITH:	Bradlee Foerschner		TIME COMPLETED:	03:30 PM

ALLEGATION(S):

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Licensee did not provide safe, comfortable accommodations for resident in care
Facility staff did not assist resident with basic care needs
Facility staff neglected resident
Facility staff did not respond timely to resident's request for assistance

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Kelly Dulek conducted a subsequent complaint investigation for the allegations listed above. LPA arrived at the facility at 09:34AM and met with Executive Director Bradlee Foerschner. Entrance interview conducted.

During today's visit, LPA conducted staff and resident interviews from 11:14AM to 1:50PM. Previously, during an initial complaint visit which took place on 03/30/2022, LPA toured the facility with Business Office Director at 10:38AM, conducted resident and witness interviews from 11:26AM to 11:50AM, interviewed Administrator Martha Berard at 12:25PM, and LPA gathered copies of pertinent documents. Throughout the course of the investigation, LPA reviewed all relevant 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: 12/07/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/07/2023

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 29-AS-20220323121610

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: 12/07/2023

NARRATIVE

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The complaint alleges that there was an incident that occurred during the overnight shift from 03/21/2022 to03/22/2022 involving Resident #1 (R1). It was alleged that R1 had called for assistance using their pendant and staff was not responding to the requests. R1 then called 9-1-1 to request assistance. Staff #1 (S1) did respond at some point, entered R1's room and assisted R1 to their bedside commode. When emergency personnel arrived at the facility S1 was in R1's room and S1 indicated they were caring for R1, so emergency personnel left the facility. S1 then left R1 on the commode and exited R1's room. R1 continued to press their pendant, but no one responded. R1 could not find their telephone to call for assistance. R1 then self-transferred back to their bed. Documents reviewed included resident's care plan and physician's report, incident report submitted by the facility Administrator, as well as statements provided by morning staff who had found R1. Interviews and documents reviewed revealed that R1's phone was found on the bedside table with the batteries removed, although typically R1 sleeps with their phone in their bed. Additionally, interviews revealed that due to R1's condition it is highly unlikely that R1 would physically be able to remove the batteries from their phone. R1 is unsure who removed the batteries from their phone, but indicated R1 did not do it themselves. S1 did indicate they had access to R1's phone when in their room to assist. Staff interviews revealed that in the morning, R1 was found in their bed with their head at the foot of the bed and feet by their pillows with their bedding tangled. Staff stated R1 was in a "urine-soaked bed" with the chuck pad soaked through, and the sheets and mattress wet with urine. Management did interview S1 in relation to the incident, but S1's statements "did not add up." As a result of the incident, S1's employment was terminated. Staff indicated 45 calls using their pendant were not responded to. R1's resident assessment does reflect that R1 requires one person physical assistance with transfers. Interviews revealed that although R1 wore an incontinence brief, it was typical that R1 would call for assistance during the overnight shift to request transfer assistance to and from the commode. Therefore, based on interview and record review, the allegations that "Licensee did not provide safe, comfortable accommodations for resident in care," "Facility staff did not assist resident with basic care needs," "Facility staff neglected resident," and "Facility staff did not respond timely to resident's request for assistance" are deemed SUBSTANTIATED at this time.

Pursuant to Title 22 Division 6 Chapter 8 of the CA Code of Regulations, the following deficiencies were cited (refer to LIC 9099-D):

Exit interview conducted. Today’s reports and appeal rights were reviewed and provided via email.

SUPERVISOR'S NAME: Kristin Heffernan	TELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Kelly Dulek	TELEPHONE: (951) 836-3170
LICENSING EVALUATOR SIGNATURE:	DATE: 12/07/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/07/2023

LIC9099 (FAS) - (06/04)

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Control Number 29-AS-20220323121610

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: 12/07/2023

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 12/21/2023 Section Cited CCR 87468.1(a)(2)	1 2 3 4 5 6 7	87468.1 Personal Rights of Residents in All Facilities (a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (2) To be accorded safe, healthful and comfortable accommodations, furnishings and equipment. This requirement is not met as evidenced by:	1 2 3 4 5 6 7	Executive Director agreed to review staff training records and provide record of personal rights training to CCL. If no training was done at the time of the incident, ED will retrain current staff on residents personal rights and provide proof of training to CCL by POC due date.
	8 9 10 11 12 13 14	Based on interview and record review, the licensee did not comply with the above cited section, as on the night of 03/21/2022, R1 was left with their bed and bedding wet with urine and no access to their phone, which posed an immediate health and safety risk to residents in care.	8 9 10 11 12 13 14
Type A 12/08/2023 Section Cited HSC 87468.2(a)(8)	1 2 3 4 5 6 7	87468.2 Additional Personal Rights of Residents in Privately Operated Facilities (a) (8)To be free from neglect, financial exploitation, involuntary seclusion, punishment, humiliation, intimidation, and verbal, mental, physical, or sexual abuse. This requirement is not met as evidenced by:	1 2 3 4 5 6 7	S1 was terminated as a result of the incident that occurred. POC cleared.
	8 9 10 11 12 13 14	Based on interview and record review, the licensee did not comply with the above cited section, as on the night of 03/21/2022, S1 left R1 on their commode and did not respond to R1's calls for assistance, which posed an immediate safety and personal rights 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: 12/07/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/07/2023

LIC9099 (FAS) - (06/04)

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