565850243-11-17-2022-29-AS-JROS-CL9Q7Z-20221117105559

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 565850243
Report Date: 11/17/2022
Date Signed: 11/17/2022 10:57:03 AM

Document Has Been Signed on 11/17/2022 10:57 AM - 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 MOORPARK		FACILITY NUMBER:	565850243
ADMINISTRATOR:	RONDA WILKIN		FACILITY TYPE:	740
ADDRESS:	13960 PEACH HILL DRIVE		TELEPHONE:	(805) 292-0700
CITY:	MOORPARK	STATE: CA	ZIP CODE:	93021
CAPACITY:	112	CENSUS: 44	DATE:	11/17/2022
TYPE OF VISIT:	Case Management - Incident	UNANNOUNCED	TIME BEGAN:	10:00 AM
MET WITH:	Ronda Wilkin		TIME COMPLETED:	10:55 AM

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Licensing Program Analyst (LPA) JoAnn Rosales conducted a subsequent Case Management visit at the above facility regarding self reported incidents. LPA met with Administrator Ronda Wilkin.

On 10/19/22, LPA Rosales began an investigation regarding self reported incidents pertaining to resident #1 (R1), R2 and Staff #1 (S1). On 10/11/22 there was a verbal incident where S1 was observed cursing at R1 by another staff. The other incident was on 10/13/22 with R2 where S1 forcefully held down R2 forcing R2 to change their briefs leaving R2 with bruising.

On 10/19/22 starting at 10:17 am LPA Rosales conducted interviews with staff and residents. On 10/25/22 starting at 9:29 am and 11/1/22 starting at 10:44 am LPA conducted interviews with staff.

S1 when interviewed on 10/19/22 am starting at 10:17 am did not recall being verbally abusive or cursing at R1. S1 when interviewed admitted to grabbing R2’s right hand on 10/13/22 while changing R2’s depends. S1 denied pinning R2 down on their bed. Interview with R1 revealed that S1 has not cursed at them but has yelled at them. Interview with R2 revealed that they do not remember how the bruising happened on their right hand and arm. Interview with S7 revealed that S1 was observed cursing at R1 telling them to shut up nobody wants to hear any of their stories. Interview with S8 revealed that they observed S1 cursing at R1 telling them to shut up saying that they did not want to hear R1’s stories. S8 stated that they observed R1 forcefully trying to get R3 off a couch in the activity room by grabbing R3’s arm. S8 stated that on 10/13/22 while trying to change R2’s briefs while R2 was in bed S1 grabbed both of R2’s hands, put them over R2’s head with their one hand while R2 was yelling and kicking. S1 grabbed R2’s ankles, pulled R2 towards them and pulled down R2’s pants ripping their briefs off of them. R2 got away from S1 and S1 held R2 by their collar for at least 10 seconds. R2 ran past S8 yelling call 911 get S1 out of their room. Interview with S9 revealed that S1 was observed cursing at R1 telling them to sit down and stop annoying them.

Continued on 809C

SUPERVISOR'S NAME: Kristin Heffernan	TELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Joann Rosales	TELEPHONE: (626) 419-4072
LICENSING EVALUATOR SIGNATURE:	DATE: 11/17/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/17/2022

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 MOORPARK	FACILITY NUMBER: 565850243
	VISIT DATE: 11/17/2022

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Interview with S10 revealed that on 10/14/22 they observed bruising on R2’s right arm. Interview with S11 revealed that they have heard S1 yelling at R1 and R3. Interview with S12 revealed that they observed S1 yell at R1 to sit down and do what they are told.

A review of R2’s records on 10/24/22 starting at 9:32 am revealed that on 10/14/22 R2 was observed to have bruising on their right arm and hand during the AM shift. During the PM shift R2 complained of neck pain. A review of S7 and S8’s written statements revealed that on 10/11/22 S1 cursed at R1 while R1 was telling stories of the past. 10/13/22 S1 physically held down R2 forcing R2 to change their underwear. On 10/13/22 R2 was screaming saying S1 beat them up and they did not want S1 in their home.

Based on the information obtained during the investigation, the allegations that S1 verbally abused R1 and physically abused R2 are substantiated at this time.

Pursuant to the California Code of Regulations, Title 22, the following deficiency is cited (please see LIC 809-D), and an immediate $500 civil penalty was assessed during today's visit on 11/17/22.

Civil penalty issued in the amount of $500.00.

Exit interview conducted. Today's reports, civil penalty and appeal rights were reviewed and emailed to the Administrator.

SUPERVISOR'S NAME: Kristin Heffernan	TELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Joann Rosales	TELEPHONE: (626) 419-4072
LICENSING EVALUATOR SIGNATURE:	DATE: 11/17/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/17/2022

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 11/17/2022 10:57 AM - 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: 11/17/2022

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 11/17/2022 Section Cited	1 2 3 4 5 6 7	1569.269 Enumerated rights; severability (a)(10) Residents of residential care facilities for the elderly shall have all of the following rights: 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:
	8 9 10 11 12 13 14	Based on interviews and record review, the licensee did not comply with the section cited above by ensuring R1 was free from verbal abuse and R2 was free from physical abuse by S1 which poses an immediate health and 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

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: Joann Rosales	TELEPHONE: (626) 419-4072
LICENSING EVALUATOR SIGNATURE:	DATE: 11/17/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/17/2022

LIC809 (FAS) - (06/04)

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