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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 565850243
Report Date: 10/19/2022
Date Signed: 10/19/2022 04:01:55 PM


Document Has Been Signed on 10/19/2022 04:01 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 MOORPARKFACILITY NUMBER:
565850243
ADMINISTRATOR:MICHAEL FOUNTAINFACILITY TYPE:
740
ADDRESS:13960 PEACH HILL DRIVETELEPHONE:
(805) 292-0700
CITY:MOORPARKSTATE: CAZIP CODE:
93021
CAPACITY:112CENSUS: 48DATE:
10/19/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
09:20 AM
MET WITH:Michael FountainTIME COMPLETED:
04:00 PM
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Licensing Program Analyst (LPA) JoAnn Rosales conducted an Case Management visit at the above facility to investigate incidents that occurred on 10/11/22 and 10/13/22 with resident #1 (R1), R2 and Staff #1 (S1). LPA met with Senior Operations Specialist Michael Fountain. Paperwork has been submitted and recently approved for a change in Administrator to Ronda Wilkin.

During today’s visit LPA toured the facility with staff Sharon Friedman and staff Fountain, interviewed random residents and staff, reviewed staff and resident records and obtained copies of pertinent documents.

During the facility tour with staff Friedman at 9:51 am LPA observed that S2 was not associated to the facility. S2 stated that they have been working at the facility since it opened. During the facility tour with staff Friedman at 10:04 am LPA observed that S3 was not associated to the facility. S3 stated that they have been working at the facility since 4/6/22. During the facility tour with staff Friedman at 10:12 am LPA observed that S4 was not associated to the facility. S4 stated that they have been working at the facility since 7/20/22. During the facility tour at 10:13 am with staff Friedman and staff Fountain LPA observed a housekeeping cart in the 2nd floor hallway with Folex carpet spot remover, Lemon-Eze bathroom creme cleanser, and Bio-Enzymatic odor elimator accessible to residents as the cart was not locked. LPA did not observe any staff in the area. During the facility tour with staff Fountain at 10:58 am LPA observed hydrogen peroxide, clorox disinfecting mist, barbicide germicide, pseudomonacine, fungicide & virucide liquid, and scissors in an unlocked beauty salon accessible to residents. During the facility tour with staff Fountain at 11:07 am LPA observed that S5 was not associated to the facility. S5 stated that they have been working at the facility since August 2022. While reviewing S1's records LPA observed that S1 was not associated to the facility. While conducting interviews at 2:11 pm LPA observed that S6 was not associated to the facility. S6 stated that they started working at the facility a couple of months ago.

Continued on 809C

SUPERVISOR'S NAME: Kristin HeffernanTELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Joann RosalesTELEPHONE: (626) 419-4072
LICENSING EVALUATOR SIGNATURE:
DATE: 10/19/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/19/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 4


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 MOORPARK
FACILITY NUMBER: 565850243
VISIT DATE: 10/19/2022
NARRATIVE
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LPA will need to return at a later to continue the investigation.

Pursuant to Title 22 Division 6 Chapter 8 of the CA Code of Regulations, the following deficiencies were cited (refer to LIC 809-D):



Civil Penalties issued in the amount of $3,000.00.

Exit interview conducted, todays reports, civil penalty and appeals rights were reviewed and emailed to the Administrator and staff Fountain.
SUPERVISOR'S NAME: Kristin HeffernanTELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Joann RosalesTELEPHONE: (626) 419-4072
LICENSING EVALUATOR SIGNATURE:

DATE: 10/19/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/19/2022
LIC809 (FAS) - (06/04)
Page: 4 of 4
Document Has Been Signed on 10/19/2022 04:01 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 MOORPARK
FACILITY NUMBER: 565850243

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/19/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
10/19/2022
Section Cited

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87355 Criminal Record Clearance (e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility: (2) Request a transfer of a criminal record clearance as specified in Section 87355(c) or
This requirement is not met as evidenced by:
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Based on LPA's observation and interviews, the licensee did not comply with the section cited above as the licensee did not ensure that S1, S2, S3, S4, S5 and S6 were associated to the facility prior to allowing S1, S2, S3, S4, S5 and S6 to work which poses an immediate safety risk to persons in care.
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Type A
10/19/2022
Section Cited

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87705 Care of Persons with Dementia (f) The following shall be stored inaccessible to residents with dementia: (1) Knives, matches, firearms, tools and other items that could constitute a danger to the resident(s).

This requirement is not met as evidenced by:
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Based on LPA's observation and record review, the licensee did not comply with the section cited above as scissors were observed in an unlocked beauty salon accessible to residents which poses an immediate health and safety risk to persons 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: Joann RosalesTELEPHONE: (626) 419-4072
LICENSING EVALUATOR SIGNATURE:
DATE: 10/19/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/19/2022
LIC809 (FAS) - (06/04)
Page: 2 of 4


Document Has Been Signed on 10/19/2022 04:01 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 MOORPARK
FACILITY NUMBER: 565850243

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/19/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
10/19/2022
Section Cited

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87705 Care of Persons with Dementia (f)(2) The following shall be stored inaccessible to residents with dementia: Over-the-counter medication, nutritional supplements or vitamins, alcohol, cigarettes, and toxic substances such as certain plants, gardening supplies, cleaning supplies and disinfectants.
This requirement is not met as evidenced by:
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Based on LPA's observations and record review, the licensee did not comply with the section cited above as toxic substances were observed accessible to residents which poses an immediate health risk to persons 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: Joann RosalesTELEPHONE: (626) 419-4072
LICENSING EVALUATOR SIGNATURE:
DATE: 10/19/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/19/2022
LIC809 (FAS) - (06/04)
Page: 3 of 4