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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 565850169
Report Date: 05/28/2024
Date Signed: 05/28/2024 11:51:00 AM

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
06/16/2022 and conducted by Evaluator Kelly Dulek
PUBLIC
COMPLAINT CONTROL NUMBER: 29-AS-20220616165315
FACILITY NAME:OAKMONT OF CAMARILLOFACILITY NUMBER:
565850169
ADMINISTRATOR:BERARD, MARTHAFACILITY TYPE:
740
ADDRESS:305 DAVENPORT STREETTELEPHONE:
(805) 738-3600
CITY:CAMARILLOSTATE: CAZIP CODE:
93012
CAPACITY:150CENSUS: 83DATE:
05/28/2024
UNANNOUNCEDTIME BEGAN:
09:12 AM
MET WITH:Bradlee FoerschnerTIME COMPLETED:
11:50 AM
ALLEGATION(S):
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9
Facility staff are not assisting with self-administration of medications as prescribed
Medications are not being refilled timely
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 subsequent complaint investigation with the purpose of delivering findings for the allegations listed above. LPA arrived at the facility 09:12AM and met with Executive Director (ED) Bradlee Foerschner. Entrance interview conducted.

During the initial complaint visit, conducted on 06/23/2022, LPA toured the facility with then-Administrator Martha Berard at 04:26PM and LPA gathered copies of pertinent documents. Throughout the course of the investigation, LPA spoke both in person and telephonically with facility staff and residents related to the complaint allegations, as well as other relevant parties. The following was then determined:

Report Continued on LIC 9099-C
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Kristin HeffernanTELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Kelly DulekTELEPHONE: (951) 836-3170
LICENSING EVALUATOR SIGNATURE:

DATE: 05/28/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/28/2024
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-20220616165315
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: 05/28/2024
NARRATIVE
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Allegation: “Facility staff are not assisting with self-administration of medications as prescribed:”
The complaint alleges that the facility staff are not assisting Resident #1 (R1) with their prescribed medications. LPA reviewed medications, Medication Administration Records (MAR), Centrally Stored Medication and Destruction Record (CSMDR), and Controlled Drug Record for R1. Record review revealed that pill #29, 27, 26, and 20 of R1’s Oxycodone-Acetaminophen were not properly documented on the Controlled Drug Record as there is no date and/or time listed that the pills were administered. Additionally, controlled drug record indicates “take 1 tab by mouth every day at 8:30AM, however, on 06/02/2022 the medication was given at 08:30AM, pill #29 was likely also administered on 06/02, however the date, time, and signature are missing. Also on 06/02/2022, staff signed that R1 took pill #28 at 12:30AM, however this could not be possible if pill #30 was administered at 08:30AM as prescribed. Additional entries include times varying from 06:00 (presumably AM), 12:30 (unclear if AM or PM), to 07:00PM. However, this document only indicates it is intended for the 08:30AM medication. Physician’s orders for R1 as well as MAR indicate R1’s Oxycodone-APAP 10/325mg is prescribed “take 1 tablet by mouth every 3 hours as needed for moderate-severe pain.” MAR indicates this medication was administered on the following dates: 2X on 06/01/2022, 3X on 06/02/2022, 06/03/2022, 06/04/2022, 06/05/2022. Then under a separate line with no prescription number marked, the medication was administered on the following dates: 2X on 06/17/2022, 06/19/2022 and 06/21/2022. Under another prescription number and a 3rd line, the medication was administered 2X on 06/20/2022. It is unclear why the medication is documented on multiple line items and the electronic record does not accurately reflect the manually written Controlled Drug Administration Record. Additionally, interviews revealed that on at least one occasion, the medication technician delivered R1’s medications to their room and left the medications in the room for R1’s private caregiver to administer to R1. R1’s private caregiver reported that one time 2 pills of the same medication were brought and left for R1 in the room, when only 1 pill was prescribed at that time. Had R1 self-administered this medication as prepared by the medication technician, R1 would have been administered twice the prescribed dose. Based on interview and record review, the allegation “facility staff are not assisting with self-administration of medications as prescribed” is deemed SUBSTANTIATED at this time. As R1 was also listed in Complaint Control # 29-AS-20220422121330, this allegation was addressed, and citation was issued under this referenced complaint, no citation will be issued during today’s visit.

Allegation: “Medications are not being refilled timely:”
The complaint alleges that medications for R1 were not refilled timely, resulting in R1’s furosemide 20mg
Report Continued on LIC 9099-C
SUPERVISOR'S NAME: Kristin HeffernanTELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Kelly DulekTELEPHONE: (951) 836-3170
LICENSING EVALUATOR SIGNATURE:

DATE: 05/28/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/28/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 29-AS-20220616165315
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: 05/28/2024
NARRATIVE
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20mg tablet not able to be administered for 2 days. R1’s MAR indicates that RX#1931532 had a stop date of 06/10/2022. Beginning with the 05:00PM dose of that medication and continuing through the 08:00AM dose on 06/12/2022, the MAR indicates exceptions stating “withheld per DR/RN orders.” R1’s MAR also indicates RX#1940373 was written on 06/10/2022. Under this prescription number, the medication does not show as administered until the 08:00AM dose on 06/15/2022 even though the prescription has an orig date of 06/10/2022. According to R1’s MAR review, R1’s furosemide 20mg tablet was not administered from 05:00PM on 06/10/2022 until 08:00AM on 06/15/2022. Staff interviewed indicated that medication technicians should be calling for refills on medications when there are approximately 8 pills remaining, but this was not always completed per policy. Staff indicated that at times R1’s medications were not refilled timely and R1 was therefore unable to receive their prescribed medications. Based on record review and interview, the allegation “medications are not being refilled timely” is deemed SUBSTANTIATED at this time. As R1 was also listed in Complaint Control # 29-AS-20220422121330, this allegation was addressed, and citation was issued under this referenced complaint, no citation will be issued during today’s visit.

Allegation: “Facility staff did not respond timely to resident's request for assistance:”
The complaint alleges that R1 was given a pendant that did not function properly, resulting in R1 experiencing long wait times when R1 requested assistance. LPA reviewed CarePoint Server Console Page Report for R1 for period of 06/08/2022 to 06/20/2022. LPA noted there were 144 total calls for assistance during this time period. Of those calls, response time ranged from 45 seconds to 1 hour, 59 minutes, 16 seconds. Interviews revealed that an acceptable call response is from 10-15 minutes maximum. LPA counted a total of 28 times during the designated time period that R1’s call response time was greater than 15 minutes. Interviews revealed that R1 did request assistance frequently, either to request PRN (as needed) medications or for transfer assistance and that sometimes residents have to wait for assistance, particularly during busy time periods. Residents interviewed also indicated at times they have to wait too long when they need assistance. Based on record review and interview, the allegation that “facility staff did not respond timely to resident’s request for assistance” is deemed SUBSTANTIATED at this time. As this allegation was also listed in Complaint Control # 29-AS-20220323121610 related to R1 and both complaints were investigated concurrently, citation was issued under this referenced complaint and no citation will be issued related to this allegation during today’s visit.

Exit interview conducted. A copy of the report and appeal rights were provided via email.
SUPERVISOR'S NAME: Kristin HeffernanTELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Kelly DulekTELEPHONE: (951) 836-3170
LICENSING EVALUATOR SIGNATURE:

DATE: 05/28/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/28/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 5
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
06/16/2022 and conducted by Evaluator Kelly Dulek
PUBLIC
COMPLAINT CONTROL NUMBER: 29-AS-20220616165315

FACILITY NAME:OAKMONT OF CAMARILLOFACILITY NUMBER:
565850169
ADMINISTRATOR:BERARD, MARTHAFACILITY TYPE:
740
ADDRESS:305 DAVENPORT STREETTELEPHONE:
(805) 738-3600
CITY:CAMARILLOSTATE: CAZIP CODE:
93012
CAPACITY:150CENSUS: 83DATE:
05/28/2024
UNANNOUNCEDTIME BEGAN:
09:12 AM
MET WITH:Bradlee FoerschnerTIME COMPLETED:
11:50 AM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Facility staff are not properly assisting resident with transfers
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Licensing Program Analyst (LPA) Kelly Dulek conducted subsequent complaint investigation with the purpose of delivering findings for the allegations listed above. LPA arrived at the facility at 09:12AM and met with Executive Director (ED) Bradlee Foerschner. Entrance interview conducted.

During the initial complaint visit, conducted on 06/23/2022, LPA toured the facility with then-Administrator Martha Berard at 04:26PM and LPA gathered copies of pertinent documents. Throughout the course of the investigation, LPA spoke both in person and telephonically with facility staff and residents related to the complaint allegations, as well as other relevant parties. The following was then determined:

Report Continued on LIC 9099-C
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Kristin HeffernanTELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Kelly DulekTELEPHONE: (951) 836-3170
LICENSING EVALUATOR SIGNATURE:

DATE: 05/28/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/28/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 29-AS-20220616165315
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: 05/28/2024
NARRATIVE
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Allegation: “Facility staff are not properly assisting resident with transfers:”

The complaint alleges that facility staff did not properly assist R1 with transfers to the commode, resulting in R1 falling. Interviews revealed that R1 does call most nights/early morning time and request to be transferred to the commode. Staff interviewed indicated that R1 has begun buckling their legs during transfers, which makes transferring R1 more difficult. Staff stated that this is what has been happening recently, which has resulted in staff having to lower R1 to the floor. Interview also revealed that some staff and private caregiver are able to safely assist R1 with transfers with only 1 person present, but due to the buckling of their legs, staff are ensuring that R1 is transferred with 2 staff present only. Resident assessment dated 08/27/2021 indicates R1 “requires one person physical assistance with transfers” and “resident has not fallen within the past year.” LPA reviewed incident reports for the indicated time period and there were no incident reports indicating R1 had fallen. Based on interview and record review, although the allegation may be valid, at this time there is insufficient evidence to support the allegation or that a violation had occurred, therefore, the allegation “facility staff are not properly assisting resident with transfers” is deemed UNSUBSTANTIATED at this time.

No citations issued related to the above allegation. Exit interview conducted. A copy of today’s report was provided.

SUPERVISOR'S NAME: Kristin HeffernanTELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Kelly DulekTELEPHONE: (951) 836-3170
LICENSING EVALUATOR SIGNATURE:

DATE: 05/28/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/28/2024
LIC9099 (FAS) - (06/04)
Page: 5 of 5