565850169-7-22-2024-29-AS-KHEN-D8CR9K-20240821124937

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 565850169
Report Date: 07/22/2024
Date Signed: 07/22/2024 10:23:28 AM

Unsubstantiated

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
07/12/2023 and conducted by Evaluator Kelly Dulek

COMPLAINT CONTROL NUMBER: 29-AS-20230712142031

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:	07/22/2024
		UNANNOUNCED	TIME BEGAN:	08:44 AM
MET WITH:	Mark Cortes, Executive Director		TIME COMPLETED:	10:35 AM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Resident sustained multiple falls and injuries while in care / Staff did not follow resident’s care plan
Staff did not provide adequate supervision to residents in care
Staff did not safeguard resident’s belongings
Staff did not conduct a proper assessment of resident in care
Staff did not provide proper medication assistance to resident in care
Staff did not provide proper food service to residents in care
Staff did not maintain facility in safe and sanitary condition
Staff did not follow doctor’s orders for resident in care
Staff did not follow proper reporting requirements

INVESTIGATION FINDINGS:

1
2
3
4
5
6
7
8
9
10
11
12
13

Licensing Program Analyst (LPA) Kelly Dulek conducted a subsequent complaint investigation for the allegations listed above. LPA arrived at the facility and was greeted by front desk staff. LPA met with Executive Director (ED) Mark Cortes at 08:53AM. Entrance interview conducted.

During the initial complaint visit on 07/20/2023, LPA interviewed ED at 02:05PM, toured the facility with Business Office Director Kailey Vanderwall at 02:11PM, and LPA reviewed and obtained copies of pertinent documents. During a subsequent complaint visit on 05/22/2024, LPA spoke with Regional Memory Care Specialist Lena Gutierrez, interviewed staff from 11:17AM to 01:15PM. LPA also reviewed pertinent documents and toured the facility's Memory Care unit with Regional Memory Care Specialist at 02:10PM. Throughout the course of the investigation, LPA interviewed additional staff both telephonically and in person and LPA reviewed all pertinent documents. The following was then determined:

Report Continued on LIC 9099-C (p. 2)

Unsubstantiated

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: 07/22/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/22/2024

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 11

Control Number 29-AS-20230712142031

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: 07/22/2024

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

Continued from LIC 9099 (p. 1)
Allegation “Resident sustained multiple falls and injuries while in care:”

It was alleged that due to lack of care and supervision, Resident #1 (R1) fell 3 (three) times while residing at the facility and sustained multiple “mysterious gashes and open wounds.” Record review revealed that R1 was admitted to the facility on 07/18/2022. R1’s physician’s report upon admit indicated R1 was ambulatory and had a diagnosis of vascular dementia; care plan assessment indicated that R1 “wanders only within the common areas of the secured community.” Incident report reviewed revealed that R1 sustained a fall on 07/31/2022, resulting in a hip fracture. According to incident report, staff and family member interview, R1 was sitting in a chair in the Memory Care outdoor area. R1 scooted their chair out and into a recessed garden bed, resulting in R1 losing their balance and falling as they attempted to stand up. A second fall occurred on 09/17/2022 resulting in an injury to the right side of R1’s head and eye area. A third fall occurred on 05/21/2023 when facility staff reported to R1’s family that R1 had fallen over their walker. Throughout the time R1 resided at the facility, R1 did not require 1:1 supervision, nor did R1 require an escort when ambulating about the secure memory care unit. Incident reports and staff interview revealed that staff were nearby when all 3 (three) falls occurred, and that staff followed the proper protocol for obtaining additional medical care and reporting the incidents. Therefore, based on interview and record review, there is insufficient evidence to support the allegation or that a violation occurred; the allegation that “resident sustained multiple falls and injury while in care” is deemed UNSUBSTANTIATED at this time.

Allegation “Staff did not provide adequate supervision to residents in care:”

It was alleged that “nobody watched [R1]” and that staff did not prevent residents from harming each other while in care. Record review revealed that at no time while R1 was residing at the facility did R1 require 1:1 supervision. Staff interviews revealed that most residents prefer to do activities or otherwise congregate in the common areas during the day. Staff indicated that all residents are checked on at least every 2 hours, even those that choose to remain in their rooms instead of engaging in activities. During the day, there are activity staff present in common areas to support the care staff and that all staff present provide supervision to residents in care. Interview revealed that there is one particular resident that has attempted to enter resident rooms and has engaged negatively with other residents on occasion. However, staff are aware of this resident and their needs and do keep a closer eye on this particular resident. Staff indicated there was an incident involving R1 and a different resident that occurred on 06/16/2023 where R1 attempted to physically Continued on LIC 9099-C (p. 3)

SUPERVISOR'S NAME: Kristin Heffernan	TELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Kelly Dulek	TELEPHONE: (951) 836-3170
LICENSING EVALUATOR SIGNATURE:	DATE: 07/22/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/22/2024

LIC9099 (FAS) - (06/04)

Page: 2 of 11

Control Number 29-AS-20230712142031

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: 07/22/2024

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

Continued from LIC 9099-C (p. 2)
fight with the other resident. Staff indicated that in this case R1 was agitated, which resulted in the incident occurring. Staff promptly separated the two residents and assessed both them for any possible injuries. Based on interview, observation, and record review revealed that at this time there is insufficient evidence to support the allegation or that a violation occurred, therefore, the allegation that “staff did not provide adequate supervision to residents in care” is deemed UNSUBSTANTIATED at this time.

Allegation “Staff did not provide proper medication assistance to resident in care:”

The complaint alleges that facility staff should have been checking R1’s blood pressure and that on occasion, R1’s family member observed medications under R1’s bed. The complaint further alleges that R1’s family member had noticed “missed doses” and because Oakmont has had allegations of medication mismanagement previously, R1’s medications must have been mismanaged as well. LPA reviewed medication records for R1, which showed that R1 had taken all prescribed medications daily in the month of June, prior to R1’s hospitalization on 06/15/2023. R1 briefly returned to the facility on 06/16/2023 and was re-hospitalized on that same day but did not return to the facility. R1’s personal items, including medications, were removed by R1’s family prior to the date the complaint was received. Therefore, R1’s medications were unable to be observed for the inconsistencies alleged. Staff interviewed indicated R1 was fairly compliant with taking their medications and no concerns were noted with R1’s medication administration. Based on interview and record review, there is insufficient evidence to support the allegation or that a violation occurred, therefore, the allegation that “staff do not provide proper medication assistance to resident in care” is deemed UNSUBSTANTIATED at this time.

Allegation “Staff did not follow resident’s care plan:”
The complaint alleges that R1 was charged for items including “fall risk management,” and “escorting” but these services were not provided to R1. Additionally, the complaint alleges that R1 was not assisted with cleaning their feet and that R1 “stayed in pajamas for days.” LPA reviewed Resident Assessment dated 07/12/2022 (pre-assessment), which indicates that R1 required “assistance with set up of grooming materials. Can groom independently,” stand-by assistance for all showering/bathing needs, medication management, and was independent for transfers and escorts. Hospital care notes indicate that although R1 required additional assistance post-fall while at the hospital, the goal during rehabilitation was to discharge R1 back to Assisted Living with stand-by assistance. Assessment dated 11/30/2022 indicates R1 requires set
Report Continued on LIC 9099-C (p. 4)

SUPERVISOR'S NAME: Kristin Heffernan	TELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Kelly Dulek	TELEPHONE: (951) 836-3170
LICENSING EVALUATOR SIGNATURE:	DATE: 07/22/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/22/2024

LIC9099 (FAS) - (06/04)

Page: 3 of 11

Control Number 29-AS-20230712142031

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: 07/22/2024

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

Continued from LIC 9099-C (p. 3)
up of grooming materials, but can groom independently, hands on assistance with bathing/showering, medication management, occasional reminders and/or escort, and fall management program. Interviews revealed that after R1’s fall and hospitalization, R1 did require additional assistance. R1 did obtain occupational therapy and physical therapy services to assist in gaining back their independence, but that R1 did not fully go back to their level of care R1 had upon admittance to the facility. Staff interviewed indicated that they attempted to assist R1 but that R1 would become agitated, particularly when certain family members were present and that R1 would refuse care when they were agitated. When certain family members weren’t present, R1’s demeanor was calmer and more receptive to receiving care assistance. As R1’s assessment indicates that R1 did not require assistance with dressing, only selection of clothing, staff did not assist R1 in changing clothes. Based on interview and record review, there is insufficient evidence to support the allegation or that a violation occurred, therefore the allegation that “staff did not follow resident’s care plan” is deemed UNSUBSTANTIATED at this time.

Allegation “Staff did not conduct a proper assessment of resident in care:”
The complaint alleges that the facility did not conduct a reassessment for R1 after their catheter was removed. LPA reviewed all documents related to R1’s care, which included care notes and 3 (three) resident assessments. When R1 moved into the facility, R1 was noted to be “occasionally incontinent of bladder or bowel and can self-manage, but requires assistance ordering and maintaining supplies.” Resident Assessment dated 08/25/2022, following R1’s fall and hospitalization indicates that R1 is “incontinent of bowel at times” and “has foley catheter.” In the section entitled “Indwelling Urinary Catheter” R1 is noted to have an indwelling catheter and needs staff monitoring and assistance from a licensed nurse. R1 was prescribed home health care to meet their needs while at the facility following the hospitalization and recovery. LPA noted that the indwelling catheter added 16 care points to R1’s care plan. Cost of Care Communication dated 08/29/2022 indicates that R1’s billable acuity score had increased from 105 on the previous assessment to 253 points currently. It is unclear when the indwelling catheter was removed, as the next resident assessment is dated 11/30/2022 and does not include points for an indwelling catheter. Interviews with Executive Director revealed that no new assessment was completed upon removal of the catheter, as the facility did not consider this a change of condition for R1 nor would the removal of the 16 points have constituted a change in R1’s level of care. With or without those points, R1’s care level remained at a level 3. When R1’s condition improved further, a new assessment was completed on 11/30/2022, Report Continued on LIC 9099-C (p. 5)

SUPERVISOR'S NAME: Kristin Heffernan	TELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Kelly Dulek	TELEPHONE: (951) 836-3170
LICENSING EVALUATOR SIGNATURE:	DATE: 07/22/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/22/2024

LIC9099 (FAS) - (06/04)

Page: 4 of 11

Control Number 29-AS-20230712142031

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: 07/22/2024

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

Continued from LIC 9099-C (p. 4)
reflecting the new level of care. Based on interview and record review, there is insufficient evidence to support the allegation or that a violation occurred, therefore, the allegation that “staff did not conduct a proper assessment of resident in care” is deemed UNSUBSTANTIATED at this time.

Allegation “Staff did not provide proper food service to residents in care:”
The complaint alleges that R1 was malnourished and was not encouraged to eat proper food. During facility visits, LPA observed food service to the residents, including breakfast and lunch service. LPA observed food served to residents in the Memory Care unit to be varied and contain adequate portions. Staff interviewed indicated that food is pre-prepared for residents in the Memory Care unit and delivered on a large covered cart to maintain food properly during delivery from the commercial kitchen located in the Assisted Living unit. Plates are prepared with the food on the menu, unless a particular resident has a special diet. R1 did have a physician-ordered heart healthy diet and the facility's regular menu is approved by a dietician and is heart healthy, low sodium for all residents in care. One of R1’s family members requested a Mediterranean diet for R1. Interviews revealed that R1 frequently refused to eat what was served and would often request different items from the facility’s order anytime menu. R1 preferred foods such as cheeseburgers or grilled cheese sandwiches. Staff interviewed reiterated that it is R1’s right to be served food of their choosing and it was important that R1 eat a meal, rather than go hungry. So when R1 refused to eat the food served and requested an alternate meal, staff would accommodate that request. Based on interview and observation, there is insufficient evidence to support the allegation or that a violation occurred, therefore, the allegation that “staff did not provide proper food service to residents in care” is deemed UNSUBSTANTIATED at this time.

Allegation “Staff did not maintain facility in safe and sanitary condition:”
The complaint alleges that R1’s restroom was not cleaned regularly, that there was blood and toothpaste observed in R1’s restroom. The complaint also alleges that R1 had access to hazards such as nail clippers and an electric shaver. Record review revealed R1 was hospitalized on 06/15/2023 and R1 only briefly returned to the facility the following day before leaving permanently. The complaint was not received until 07/12/2023, so the initial visit was conducted about a month after R1 moving out of the facility, therefore, LPA could not observe the condition of R1’s room while R1 resided there or immediately afterward. During the initial complaint visit, LPA Dulek toured and took photographs of R1’s former room. LPA did not observe any blood or toothpaste in R1’s restroom. LPA toured other rooms in the memory care unit and all rooms appeared to be relatively clean and sanitary. During a subsequent visit, LPA observed housekeeping staff
Report Continued on LIC 9099-C (p. 6)

SUPERVISOR'S NAME: Kristin Heffernan	TELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Kelly Dulek	TELEPHONE: (951) 836-3170
LICENSING EVALUATOR SIGNATURE:	DATE: 07/22/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/22/2024

LIC9099 (FAS) - (06/04)

Page: 5 of 11

Control Number 29-AS-20230712142031

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: 07/22/2024

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

Continued from LIC 9099-C (p. 5)
cleaning rooms. Staff interviewed indicate that housekeeping is scheduled regularly to clean resident rooms/restrooms and that care staff assist with cleaning the common areas of the facility, as time permits during their scheduled shifts. Care staff empty resident trash cans daily on each shift. Staff indicated there are times when housekeeping isn’t completed per the schedule, depending on staffing, but that rooms remain relatively clean. Interviews also revealed that all sharp objects remain secured in the Memory Care unit. Staff interviewed indicated that the previous Memory Care Director had stored some residents’ nail clippers and shavers labeled and locked in the medication room if a resident did not have a lock on their restroom cabinet. Review of R1’s physician report and needs and service assessment indicated that R1 is not at risk if allowed direct access to personal grooming and hygiene items and that R1 “can groom independently.” As R1 is not at risk with these items, it is R1’s personal right to be allowed to groom themselves independently. Based on interview and record review, there is insufficient evidence to support the allegation or that a violation occurred, therefore, the allegation that “staff did not maintain facility in safe and sanitary condition” is deemed UNSUBSTANTIATED at this time.

Allegation “Staff did not safeguard resident’s belongings:”
The complaint alleges that items belonging to R1, including a trash can, shavers and chargers went missing and various other residents (not including R1) were wearing other residents’ clothing. LPA reviewed R1’s facility file, which included a document entitled “Optional Inventory of Personal Property”. This document allows the resident to provide an inventory of items brought into the facility for safeguarding by facility staff. However, R1’s responsible party marked the box indicating “I do not wish to inventory personal property” and signed the form upon admit to the facility. Interviews revealed that R1’s family did not provide any other listing of R1’s items and that different family members visited R1 at the facility and had access to R1’s personal belongings in R1’s room regularly. Staff interviewed indicated that all residents in the memory care unit have a locked cabinet in their private restroom where personal grooming items, such as shavers are stored locked and inaccessible to residents in care. Although R1 did not have a roommate at the time of the complaint allegation, R1 did occupy a shared room and did have a roommate part of the time they resided at the facility. Staff indicated that both residents’ grooming items would have been stored in the same locked cabinet and since there was no written inventory of R1’s items, staff would have been unable to ascertain which specific items belonged to R1 and which belonged to the roommate. Both staff and management interviewed indicated that when R1 moved out, the family did take a shaver and charger with them. With Report Continued on LIC 9099-C (p. 7)

SUPERVISOR'S NAME: Kristin Heffernan	TELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Kelly Dulek	TELEPHONE: (951) 836-3170
LICENSING EVALUATOR SIGNATURE:	DATE: 07/22/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/22/2024

LIC9099 (FAS) - (06/04)

Page: 6 of 11

Control Number 29-AS-20230712142031

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: 07/22/2024

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

Continued from LIC 9099-C (p. 6)
regard to residents’ clothing items, interviews revealed that each resident maintains and stores their own personal clothing in their personal room. Facility staff wash each resident’s laundry separately and return the laundry directly to the resident’s room. Staff stated that often when a resident passes away, the family will donate the resident’s clothing to other residents in need or to the facility to utilize for residents who may not have enough clothing. Interviews revealed that it is only with family approval that they will give clothing to a particular resident in need. Staff interviewed indicated there have been no concerns with incorrect clothing with any other resident or their families. Based on interview and record review, there is insufficient evidence to support the allegation or that a violation occurred, therefore, the allegation that “staff did not safeguard resident’s belongings” is deemed UNSUBSTANTIATED at this time.

Allegation “Staff did not follow doctor’s orders for resident in care:”
The complaint alleges that the facility did not ensure R1’s orders for knee-high compression socks were worn, nor did the facility provide a heart-healthy diet. LPA reviewed R1’s needs and service appraisal and noted that R1 did not have compression socks upon admittance to the facility. Assessment dated 08/25/2022 also did not indicate R1’s need for compression hose, however the 11/30/2022 assessment did include R1 “requires assistance with applying and removing compression hose.” Interviews with staff revealed that staff did assist R1 in putting on the compression hose, as R1 would allow. Often, R1 would become agitated and try to hit staff when they attempted to assist R1 with their compression hose. When staff did get the compression hose on, interviews revealed that R1 would either take off their compression hose or pull it down and not wear it properly. Staff interviewed indicated they attempted to assist R1 daily with compression hose, but R1 did not allow the compression hose to be on their legs most days. Record review revealed that R1’s doctor did indicate a heart-healthy diet on R1’s physician’s report dated 08/19/2022. Interview with staff revealed that the regular menus and food selection for Oakmont is all a low-sodium and heart healthy menu. No special diet was necessary for R1, as the provided menu is in line with R1’s doctor’s orders. However, staff interviewed indicated that R1 refused to eat the meals provided to R1 on a regular basis. All food from the regular menu was prepared in the kitchen and delivered to the Memory Care unit, but when R1 refused to eat the food provided, R1 was allowed to order an alternative choice. Staff interviewed indicated they informed both the resident’s responsible party as well as R1’s physician that R1 was ordering items such as cheeseburgers and grilled cheese, rather than eating from the provided menu. Staff interviews revealed that R1 was encouraged to eat per their diet, but R1 refused. Based on interview and record review, there is Report Continued on LIC 9099-C (p. 8)

SUPERVISOR'S NAME: Kristin Heffernan	TELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Kelly Dulek	TELEPHONE: (951) 836-3170
LICENSING EVALUATOR SIGNATURE:	DATE: 07/22/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/22/2024

LIC9099 (FAS) - (06/04)

Page: 7 of 11

Control Number 29-AS-20230712142031

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: 07/22/2024

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

Continued from LIC 9099-C (p. 7)
insufficient evidence to support the allegation or that a violation occurred, therefore, the allegation that “staff did not follow doctor’s orders for resident in care” is deemed UNSUBSTANTIATED at this time.

Allegation “Staff did not follow proper reporting requirements:”
The complaint alleges that the facility did not report an unusual incident to the police, although ED indicated it had been reported. LPA reviewed information provided, including a police report number. Upon further inquiry, LPA discovered that police had been out and interviewed both facility staff and residents on the date in question, however no report was written by the police department, as both residents involved have a diagnosis of dementia. Staff and management interviewed indicated that the police were present at the facility and conducted interviews. The incident was reported to Community Care Licensing (CCL) both over the telephone and in writing and an Alleged Abuse Report was filed with Adult Protective Services (APS) and Long Term Care Ombudsman (LTCO). Based on interview and record review, there is insufficient evidence to support the allegation or that a violation occurred, therefore, the allegation that “staff did not follow proper reporting requirements” is deemed UNSUBSTANTIATED at this time.

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

SUPERVISOR'S NAME: Kristin Heffernan	TELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Kelly Dulek	TELEPHONE: (951) 836-3170
LICENSING EVALUATOR SIGNATURE:	DATE: 07/22/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/22/2024

LIC9099 (FAS) - (06/04)

Page: 8 of 11

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
07/12/2023 and conducted by Evaluator Kelly Dulek

COMPLAINT CONTROL NUMBER: 29-AS-20230712142031

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:	07/22/2024
		UNANNOUNCED	TIME BEGAN:	08:44 AM
MET WITH:	Mark Cortes, Executive Director		TIME COMPLETED:	10:35 AM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Staff refused to accept resident back to the facility

INVESTIGATION FINDINGS:

1
2
3
4
5
6
7
8
9
10
11
12
13

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: 07/22/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/22/2024

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

LIC9099 (FAS) - (06/04)

Page: 9 of 11

Control Number 29-AS-20230712142031

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: 07/22/2024

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

Continued from LIC 9099-A (p. 9)

Allegation: “Staff refused to accept resident back to the facility:”

LPA reviewed resident records for R1 and conducted interviews. Record review revealed that R1 had increasing agitation, aggression and exit seeking in June 2023. This behavior resulted in staff calling 9-1-1 on 06/15/2023 and paramedics taking R1 to the hospital. Interviews revealed that R1 returned to the facility on 06/16/2023, but later that evening, there was an altercation between R1 and another resident which resulted in R1 being sent to the hospital again. By 06/17/2023, the hospital planned to discharge R1 back to the facility, however facility management did not allow R1 to return to the facility. Interview revealed that it was a corporate decision, made above the local level, to refuse R1’s return to the facility. Additional staff interviews revealed that R1 had been showing increasing agitation and aggressive behavior and that R1 required a higher level of care. LPA reviewed documents sent to Community Care Licensing (CCL) and noted that the facility had not issued a valid eviction notice for R1 at any time. Based on record review and interview, there is sufficient evidence to support the allegation, therefore the allegation that “staff refused to accept resident back to the facility” is deemed SUBSTANTIATED at this time.

Pursuant to Title 22 of the CA Code of Regulations and/or CA Health and Safety Code, the following deficiency was cited (refer to LIC 9099-D):

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

SUPERVISOR'S NAME: Kristin Heffernan	TELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Kelly Dulek	TELEPHONE: (951) 836-3170
LICENSING EVALUATOR SIGNATURE:	DATE: 07/22/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/22/2024

LIC9099 (FAS) - (06/04)

Page: 10 of 11

Control Number 29-AS-20230712142031

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: 07/22/2024

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 07/29/2024 Section Cited CCR 87468.2(a)(20)	1 2 3 4 5 6 7	87468.2 (a) (20) To be protected from involuntary transfers, discharges, and evictions... for residents. For purposes of this paragraph, "involuntary" means a transfer, discharge, or eviction that is initiated by the licensee, not by the resident. This requirement is not met as evidenced by:	1 2 3 4 5 6 7	As R1 no longer resides in the facility, ED agreed to send to CCL a statement of understanding related to resident transfer, involuntary discharge, and evictions by POC due date.
	8 9 10 11 12 13 14	Based on interview and record review, the facility did not comply with the above cited section, as R1 was sent to the hospital on 06/16/2022 and the facility refused to accept R1 back to the facility following hospital discharge, which poses a potential personal rights risk to persons 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: 07/22/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/22/2024

LIC9099 (FAS) - (06/04)

Page: 11 of 11