567609903-3-22-2023-29-AS-DPEA-CRBRB7-20230428125216

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 567609903
Report Date: 03/22/2023
Date Signed: 03/22/2023 07:02:59 PM

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
06/08/2021 and conducted by Evaluator Kelly Dulek

PUBLIC

COMPLAINT CONTROL NUMBER: 29-AS-20210608194241

FACILITY NAME:	OAKMONT OF CAMARILLO		FACILITY NUMBER:	567609903
ADMINISTRATOR:	LEATRICE BOGOYEVAC		FACILITY TYPE:	740
ADDRESS:	305 DAVENPORT STREET		TELEPHONE:	(805) 738-3600
CITY:	CAMARILLO	STATE: CA	ZIP CODE:	93012
CAPACITY:	0	CENSUS: 0	DATE:	03/22/2023
		UNANNOUNCED	TIME BEGAN:	11:00 AM
MET WITH:	Bradlee Foerschner		TIME COMPLETED:	06:41 PM

ALLEGATION(S):

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The licensee did not provide assistance in meeting resident's necessary medical needs

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Kelly Dulek conducted an unannounced subsequent complaint inspection at the facility today. The LPA arrived at 11:00AM and initially met with Business Office Manager Kailey Vanderwall. Executive Director Bradlee Foerschner joined during the facility tour. The LPA informed both managers of the reason for today's inspection. Entrance interview conducted.

This report is being delivered to the current Executive Director Bradlee Foerschner, of Oakmont of Camarillo (LIC # 565850169) per prior approval of Susan McPherson, Senior Vice President of Regulatory Affairs for the management company.

During today’s visit, LPA toured the facility with Ms. Vanderwall at 11:04AM, interviewed staff at 11:42AM and 12:19PM, LPA observed lunch in the Memory Care unit at 12:09PM, and LPA conducted a medication review with ED and the Medication Technician at 12:52PM. During a subsequent complaint visit conducted on
REPORT CONTINUED ON LIC 9099-C

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: 03/22/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/22/2023

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 6

Control Number 29-AS-20210608194241

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: 567609903
	VISIT DATE: 03/22/2023

NARRATIVE

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Continued from LIC 9099...
03/02/2023, LPA conducted an interview with ED Foerschner at 12:15PM, gathered and reviewed pertinent documents, and interviewed staff between 01:50PM and 03:27PM. During an initial complaint visit conducted on 06/09/2021, LPA Dulek conducted an interview with Administrator Lea Bogoyevac at 2:42PM and again at 5:15PM, staff interviews between 3:40 and 4:45PM, reviewed medications at 4:46PM and gathered copies of documents pertinent to the investigation. The following was then determined:

The complaint alleges that after a brief hospitalization, the facility did not provide transportation for Resident #1 (R1) to return to the facility. Interview with R1, who resides in the Assisted Living unit of the facility, revealed that R1 had to call and arrange for a Lyft, as the facility was unable to provide transportation. Interview with staff revealed that the facility has a driver who works Monday through Friday during normal business hours. When residents need a ride, they can ask the concierge. The concierge keeps a calendar containing the driver's availability. In Assisted Living, with a few exceptions such as if the resident asks for assistance, residents schedule their own appointments with their medical or dental providers, then they inform the concierge of the time and date of their appointment. The concierge puts the appointment on the calendar. The driver then periodically checks the calendar, speaks with residents a day or 2 prior to their appointment, to remind them of their scheduled appointment and the confirmed departure time. Each day when the driver works, they will take a photograph of the calendar for the day to ensure no appointments are missed. Interview revealed that there are no drivers currently available or employed on Saturdays and Sundays. There is a plan to change that schedule to accommodate weekend transportation needs, however, at the time of the complaint, no transportation was provided by the facility on the weekends. The day R1 was discharged from the hospital fell on a Saturday. The facility was informed just prior to R1 being discharged, and the facility informed the hospital that they were unavailable for transportation. Interview revealed that in the event a resident cannot arrange their own transportation, the facility will contact their preferred alternate medical transportation provider, will make the arrangements for the resident, pay up front for the service, and then subsequently bill the resident for the service. Based on interview, at this time there is insufficient evidence to support the allegation or that a violation occurred, therefore, the allegation that "the licensee did not provide assistance in meeting resident's necessary medical needs" is deemed UNSUBSTANTIATED at this time.

Exit interview conducted. No citations issued in relation to the above complaint allegation. A copy of the 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: 03/22/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/22/2023

LIC9099 (FAS) - (06/04)

Page: 2 of 6

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
06/08/2021 and conducted by Evaluator Kelly Dulek

PUBLIC

COMPLAINT CONTROL NUMBER: 29-AS-20210608194241

FACILITY NAME:	OAKMONT OF CAMARILLO		FACILITY NUMBER:	567609903
ADMINISTRATOR:	LEATRICE BOGOYEVAC		FACILITY TYPE:	740
ADDRESS:	305 DAVENPORT STREET		TELEPHONE:	(805) 738-3600
CITY:	CAMARILLO	STATE: CA	ZIP CODE:	93012
CAPACITY:	0	CENSUS: 0	DATE:	03/22/2023
		UNANNOUNCED	TIME BEGAN:	11:00 AM
MET WITH:	Bradlee Foerschner		TIME COMPLETED:	06:41 PM

ALLEGATION(S):

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Facility staff did not administer medications as prescribed

INVESTIGATION FINDINGS:

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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: 03/22/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/22/2023

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

LIC9099 (FAS) - (06/04)

Page: 3 of 6

Control Number 29-AS-20210608194241

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: 567609903
	VISIT DATE: 03/22/2023

NARRATIVE

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Continued from LIC 9000-A...
03/02/2023, LPA conducted an interview with ED Foerschner at 12:15PM, gathered and reviewed pertinent documents, and interviewed staff between 01:50PM and 03:27PM. During an initial complaint visit conducted on 06/09/2021, LPA Dulek conducted an interview with Administrator Lea Bogoyevac at 2:42PM and again at 5:15PM, staff interviews between 3:40 and 4:45PM, reviewed medications at 4:46PM and gathered copies of documents pertinent to the investigation. The following was then determined:

It was alleged that medications were not administered properly for at least two (2) residents: Resident #1 (R1) and Resident #2 (R2.) During the initial complaint inspection on 06/09/2021, LPA reviewed medications for R2. The following was noted: R2 had no Tylenol (Acetaminophen) on their centrally stored medication record, although this medication is ordered as a PRN medication. R2's Gabapentin was also not on their centrally stored medication record and this medication is scheduled daily. Additionally, R2's Oxycodone had no start date indicated and 180 out of 240 total pills were present in the facility at the time of the medication review. Medication Administration Record (MAR) for R2 provided indicates Oxycodone-Acetaminophen 10-325 was ordered as a PRN medication and discontinued on 05/18/2021, but was administered 2-3 times daily through 05/25/2021. Oxycodone-Acetaminophen 10-325 was ordered as routine every 3 hours written on 05/17/2021 and discontinued on 05/18/2021, however was marked as administered 8 times on the MAR on 05/25/2021, every 3 hours beginning at 12:00AM through 09:00PM. Review of June 2021 MAR for R2 indicated Oxycodone-Acetaminophen 10-325 PRN indicates an orig. date of 05/17/2021, but date written 05/28/2021. MAR indicates resident was not administered Oxycodone-Acetaminophen 10-325 between 05/26/2021 - 05/31/2021, although resident interview revealed that R2 did request this PRN medication. Review of R1's assessment dated 05/04/2021 indicates R1 "requires routine medication management...up to 3 times per day." Physician's report dated 04/08/2021 indicates "patient is not able to manage medications and nurse has to help dispense the medication to the patient for both scheduled and PRN medications." Preplacement appraisal also indicates medications "need to be supplied and provided to [R1] at appropriate intervals." However, computerized care assessment indicated R1 did not require medication management until 07/07/2021, when an updated assessment was completed. However, MAR records were kept for R1 beginning in May 2021. Care notes revealed that on 05/14/2021 and 05/15/2021, R1 was "concerned of not getting all of [R1's] meds." MAR review revealed that Hydroxyzine Hydroclorid 25mg was not initialed as administered on 05/14/2021 and 05/28/2021 and R1's Demadex 20mg was not initialed as administered on 05/15/2021 and 05/28/2021.
Report Continued on LIC 9099-C

SUPERVISOR'S NAME: Kristin Heffernan	TELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Kelly Dulek	TELEPHONE: (951) 836-3170
LICENSING EVALUATOR SIGNATURE:	DATE: 03/22/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/22/2023

LIC9099 (FAS) - (06/04)

Page: 4 of 6

Control Number 29-AS-20210608194241

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: 567609903
	VISIT DATE: 03/22/2023

NARRATIVE

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Continued from LIC 9099-C...
Additionally, R1's Folic Acid, Metformin HCL, Metopropol Succ ER, and Omeprazole DR 20mg were not marked as administered 05/18/2021 through 05/26/2021. R1's June MAR indicates none of R1's medications were administered 06/07/2021 through 06/13/2021. Based on interview and record review, the allegation that "facility staff did not administer medications as prescribed" is deemed SUBSTANTIATED at this time.

Pursuant to Title 22 CA Code of Regulations, the following deficiency was cited (refer to LIC 9099-D).

Exit interview conducted with Executive Director Bradlee Foerschner. A copy of the report and appeal rights were provided.

SUPERVISOR'S NAME: Kristin Heffernan	TELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Kelly Dulek	TELEPHONE: (951) 836-3170
LICENSING EVALUATOR SIGNATURE:	DATE: 03/22/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/22/2023

LIC9099 (FAS) - (06/04)

Page: 5 of 6

Control Number 29-AS-20210608194241

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: 567609903
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 03/22/2023

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 03/23/2023 Section Cited CCR 87465(a)(4)	1 2 3 4 5 6 7	87465 (a)A plan for incidental medical and dental care shall be developed by each facility....by compliance with the following: (4) The licensee shall assist residents with self-administered medications as needed. This requirement is not met as evidenced by:	1 2 3 4 5 6 7	Due to a Change of Ownership which took place on 10/11/2021, the facility is closed.
	8 9 10 11 12 13 14	Based on record review and interview, the licensee did not comply with the above cited section, as no medications were marked on the MAR for R1 for 6 days in June 2021 and R2's Percocet was marked discontinued but administered which posed an immediate health and safety risk to residents 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: 03/22/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/22/2023

LIC9099 (FAS) - (06/04)

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