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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 567609903
Report Date: 05/08/2023
Date Signed: 05/08/2023 03:08:26 PM

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
04/09/2021 and conducted by Evaluator Kasandra Lopez
COMPLAINT CONTROL NUMBER: 29-AS-20210409080302
FACILITY NAME:OAKMONT OF CAMARILLOFACILITY NUMBER:
567609903
ADMINISTRATOR:LEATRICE BOGOYEVACFACILITY TYPE:
740
ADDRESS:305 DAVENPORT STREETTELEPHONE:
(805) 738-3600
CITY:CAMARILLOSTATE: CAZIP CODE:
93012
CAPACITY:0CENSUS: 0DATE:
05/08/2023
UNANNOUNCEDTIME BEGAN:
11:37 AM
MET WITH:Sue McPhersonTIME COMPLETED:
11:38 AM
ALLEGATION(S):
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Facility staff are not properly trained.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) KaSandra Lopez conducted a subsequent tele-visit telephonically at 2:47 PM with Sue McPherson, Senior Vice President of Regulatory Affairs for Oakmont Management Group. The facility closed on 10/21/2021 and was relicensed. The purpose of the call is to conclude an investigation initiated by LPA Lopez on 04/13/2021 and provide the complaint findings.
On 04/09/2021, the Department received a complaint regarding the above allegation. On 04/13/2021, from 3:07pm to 5:25pm, LPA Lopez conducted the initial complaint visit. LPA Lopez arrived at 3:07pm and met with Administrator Lea Bogoyevac at approximately 3:30pm. The LPA informed the Administrator of the reason for the visit. During the visit, the LPA conducted an interview with the Administrator and conducted record review beginning at 3:56pm. The LPA reviewed records for three residents, including Resident #1 (R1), and obtained pertinent copies. The LPA informed the Administrator that CCLD IB Investigator Tiffany Brunelli was assigned to investigate the allegation. On 05/24/2021, Investigator Brunelli conducted interviews with Staff #1 (S1) and Staff #2 (S2) and attempted to interview R1.
Report continued on LIC 9099-C.
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Desaree PereraTELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Kasandra LopezTELEPHONE: (818) 421-5183
LICENSING EVALUATOR SIGNATURE:

DATE: 05/08/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/08/2023
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 7
Control Number 29-AS-20210409080302
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: 05/08/2023
NARRATIVE
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On 06/09/2021, from 2:42pm to 5:30pm, LPA Lopez conducted an unannounced subsequent complaint investigation at the facility. The LPA met with Administrator Lea Bogoyevac at 2:42pm and explained the reason for the visit. At 3:28pm the LPA conducted an interview with the Administrator. At 3:34pm the LPA conducted a telephone interview with a Staff #1 (S1). At 3:40pm an interview was conducted with Staff #9 (S9) and reviewed medications. Please note S9 was previously mistakenly identified as Staff #2 (S2) on the 06/09/2021 report. Records reviewed and copies of pertinent records were obtained.

On 07/08/2021, CCLD IB Investigator Peter Zertuche was assigned to continue to investigate the allegation. On 07/12/2021, at approximately 4:30pm, Investigator Zertuche contacted Detective Ryan Clark of the Ventura County Sheriff’s Department via email; a follow up contact was made on 07/14/2021, at approximately 8:30am; on 07/29/2021, at approximately 10:45am; and on 08/16/2021, at approximately 11:30am. On 08/17/2021, at approximately 10:00am, Investigator Zertuche and Detective Clark conducted a joint interview with S2.

On 08/12/2021, at approximately 3:00pm, Investigator Zertuche interviewed S4 and Staff #5 (S5); on 08/17/2021, at approximately 10:00am, with S2; on 08/19/2021, at approximately 11:00am, with the At Home Care Director (outside home care agency) that employed I1. On 09/14/2021, at approximately 2:00pm, Investigator Zertuche attempted to contact I1, but the phone number was not valid; on 09/15/2021, a contact letter was sent to I1, but no response was received. I1 was unable to be contacted or interviewed.

On 03/18/2022, LPA Kelly Dulek conducted a subsequent inspection at the facility and delivered complaint findings for two allegations from this complaint.

On 04/21/2022, LPA Lopez conducted a telephone interview with Staff #6 (S6) at 1:29 PM.

On 04/22/2022, LPA Lopez conducted an inspection at the facility currently licensed as 565850169 and the LPA conducted an interview with Staff #7 (S7), reviewed medication records, and obtained copies of pertinent records.

On 04/25/2022, LPA Lopez conducted a telephone interview with Staff #8 (S8) at 3:42 PM. On 04/27/2022 LPA Lopez conducted a telephone interview with S9 at 2:29 PM. On 04/28/2022, LPA Lopez conducted a telephone interview with S1 at 1:19 PM and on 04/29/2022 with former Administrator Leatrice Bogoyvac at 2:11 PM. On 04/25/2022 and 04/26/2022, the LPA attempted to conduct telephonic interviews with S2 and Staff #10 (S10) but did not receive a returned call. Report continued on LIC 9099-C.

SUPERVISOR'S NAME: Desaree PereraTELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Kasandra LopezTELEPHONE: (818) 421-5183
LICENSING EVALUATOR SIGNATURE:

DATE: 05/08/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/08/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 7
Control Number 29-AS-20210409080302
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: 05/08/2023
NARRATIVE
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Facility staff are not properly trained.

The allegation of ‘Facility staff are not properly trained’ alleged Medication Technicians, "Med Techs" were not trained properly and as long as they passed the test and shadowed for a few hours they were qualified enough to pass medications. For facilities licensed to care for 16 or more residents, staff who assist residents with the self administration of medications are required to have 24 hours of training, including 16 hours of hands-on shadowing and eight hours of other training or instruction. The LPA reviewed records for seven Med Techs who were employed between May 2020 through April 2021. Six out of seven staff had less than 8 hours of documented training and all seven staff did not have documentation of receiving 16 hours of shadowing. During the 04/22/2022, the LPA confirmed with Administrator at the time Martha Berard that they had no record of these staff receiving 16 hours of documented hands-on shadowing. Based on the information obtained, there is sufficient evidence to support the allegation occurred. Therefore, the allegation 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. A copy of the report and appeal rights were emailed to Ms. McPherson for signature.

SUPERVISOR'S NAME: Desaree PereraTELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Kasandra LopezTELEPHONE: (818) 421-5183
LICENSING EVALUATOR SIGNATURE:

DATE: 05/08/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/08/2023
LIC9099 (FAS) - (06/04)
Page: 3 of 7
Control Number 29-AS-20210409080302
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: 05/08/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
05/08/2023
Section Cited
HSC
1569.69
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§1569.69(a) (1) In facilities licensed to provide care for 16 or more persons, the employee shall complete 24 hours of initial training. This training shall consist of 16 hours of hands-on shadowing training,...and 8 hours of other training or instruction,...
This requirement is not met as evidenced by:
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There is no plan of correction. The facility closed effective 10/21/2021 with a change of ownership.
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Based on record review, the licensee failed to comply with the section cited about as 7 out of 7 staff files reviewed did not have completed medication training which poses a potential 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: Desaree PereraTELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Kasandra LopezTELEPHONE: (818) 421-5183
LICENSING EVALUATOR SIGNATURE:

DATE: 05/08/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/08/2023
LIC9099 (FAS) - (06/04)
Page: 4 of 7
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
04/09/2021 and conducted by Evaluator Kasandra Lopez
COMPLAINT CONTROL NUMBER: 29-AS-20210409080302

FACILITY NAME:OAKMONT OF CAMARILLOFACILITY NUMBER:
567609903
ADMINISTRATOR:LEATRICE BOGOYEVACFACILITY TYPE:
740
ADDRESS:305 DAVENPORT STREETTELEPHONE:
(805) 738-3600
CITY:CAMARILLOSTATE: CAZIP CODE:
93012
CAPACITY:0CENSUS: 0DATE:
05/08/2023
UNANNOUNCEDTIME BEGAN:
11:37 AM
MET WITH:Sue McPhersonTIME COMPLETED:
11:38 AM
ALLEGATION(S):
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Facility falsified resident's records.
Facility mismanaged residents' medications.
Facility did not properly document residents' changes of conditions.
Facility staff failed to assist with the self-administration of medications as ordered.
Facility staff gave a resident medication prescribed to another resident
INVESTIGATION FINDINGS:
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Allegation: Facility falsified resident records
The allegation of ‘Facility falsified resident records’ alleges documents in Resident #1 (R1) file and a written statement by S4 pertaining to an alleged incident regarding R1 were removed from R1’s file. During the interview with S6, they stated when they were made aware of the alleged incident on 02/01/2021, they also documented in R1’s chart notes. Information received during the investigation revealed S4 sent an email correspondence to the Administrator Leatrice Bogoyvac, S1 and S5 on 02/01/2021 reporting an incident they allegedly observed pertaining to R1.

During the inspection on 04/13/2021 and 06/09/2021, the LPA conducted record review of R1’s file and did not observe any written documentation in R1’s file pertaining to the alleged incident. LPA Lopez reviewed the chart notes for R1 in file, and there were entries on R1’s resident care notes on 01/05/2021 and 02/05/2021 but there was no written entry for 02/01/2021. Report continued on LIC 9099-C.
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Desaree PereraTELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Kasandra LopezTELEPHONE: (818) 421-5183
LICENSING EVALUATOR SIGNATURE:

DATE: 05/08/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/08/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 5 of 7
Control Number 29-AS-20210409080302
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: 05/08/2023
NARRATIVE
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 Information obtained through the course of the interview found no witnesses to documents being removed from R1’s file. Interviews with S1 and the Administrator revealed they were not aware of any documents being removed from R1’s file. Based on the information obtained, there is insufficient evidence to support any particular staff at the facility intentionally removed documents from R1’s file to falsify records. Therefore, the allegation of Facility falsified resident records is deemed unsubstantiated.

Allegation: Facility mismanaged residents' medications

The allegation of ‘Facility mismanaged residents' medications alleges a continued issue with medication status and availability due to Staff #1 (S1) not reviewing new medications in their EMAR system creating a backlog of medications that need to be approved prior to being dispensed to the residents by the medication tech. The allegation also alleges when medication was missing, S1 instructed Staff #6 (S6) to document that a missing pill fell in the drawer. During the interview with S1, they stated in addition to them self, four other staff were trained to enter medications in their EMAR system and approve. S1 also stated if medications were not entered in EMAC, staff could always document on paper records until it could be entered. S1 recalled an incident with S6 when a medication was missing for a resident which was later found in the drawer and documented. During the interview with S6, they stated when medications were missing, S1 would document the pill fell in the drawer. Based on the information obtained, there is insufficient evidence to support the allegation occurred. Therefore, the allegation of Facility mismanaged residents' medications is deemed unsubstantiated at this time.

Facility staff failed to assist with the self-administration of medications as ordered.

The allegation of ‘Facility staff failed to assist with the self-administration of medications as ordered’ alleges multiple medication errors by multiple staff. Interviews revealed staff recalled medication errors with other staff members and missing medications but could not recall any specific occurrences during the time this complaint was filed. Based on the information obtained, there is insufficient evidence to support the allegation occurred. Therefore, the allegation of Facility staff failed to assist with the self-administration of medications as ordered is deemed unsubstantiated at this time.

Continued on LIC 9099-C.

SUPERVISOR'S NAME: Desaree PereraTELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Kasandra LopezTELEPHONE: (818) 421-5183
LICENSING EVALUATOR SIGNATURE:

DATE: 05/08/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/08/2023
LIC9099 (FAS) - (06/04)
Page: 6 of 7
Control Number 29-AS-20210409080302
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: 05/08/2023
NARRATIVE
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Facility did not properly document residents' changes of conditions.

The allegation of ‘Facility did not properly document residents' changes of conditions’ alleges proper documentation of residents’ changes of condition was not done due to lack of training. Although record review revealed seven staff did not receive sufficient medication training, based on interviews and record review there is insufficient evidence to support this allegation occurred. Therefore, the allegation of ‘Facility did not properly document residents' changes of conditions’ is deemed unsubstantiated at this time.

Facility staff gave a resident medication prescribed to another resident

The allegation of ‘Facility staff gave a resident medication prescribed to another resident alleges Resident #3 (R3) ran out of oxycodone and Staff #1 (S1) instructed Med Tech Staff #10 (S10) to pull from another resident since they take the same medication. During the interview with S1, they denied ever instructing staff to use the medication of another resident for R3. LPA attempted to interview S10 on two occasions but S10 did not return the telephone calls. Other staff interviewed were not aware of anyone being instructed to give a resident medication prescribed to another resident. Based on the information obtained, there is insufficient evidence to support the allegation occurred. Therefore, the allegation is deemed unsubstantiated at this time

Exit interview conducted. Appeal rights and copy of report were emailed for signature.

SUPERVISOR'S NAME: Desaree PereraTELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Kasandra LopezTELEPHONE: (818) 421-5183
LICENSING EVALUATOR SIGNATURE:

DATE: 05/08/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/08/2023
LIC9099 (FAS) - (06/04)
Page: 7 of 7