567609903-3-21-2022-29-AS-DPEA-CS727Q-20230525170905

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 567609903
Report Date: 03/18/2022
Date Signed: 03/21/2022 10:02:18 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
04/09/2021 and conducted by Evaluator Kelly Dulek

PUBLIC

COMPLAINT CONTROL NUMBER: 29-AS-20210409080302

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:	03/18/2022
		UNANNOUNCED	TIME BEGAN:	01:35 PM
MET WITH:	Kailey Vanderwall		TIME COMPLETED:	06:55 PM

ALLEGATION(S):

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Neglect/Lack Supervision: Resident #1 (R1) was inappropriately touched by an outside home care agency worker

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Kelly Dulek conducted a subsequent complaint visit to the above noted facility. The purpose of the visit is to conclude an investigation initiated by LPA Lopez on 04/13/2021. LPA met with Business Office Director Kailey Vanderwall and explained the reason for the visit.

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

On 04/09/2021, the Department received a complaint regarding an allegation of Neglect/Lack of Supervision. It was alleged that on 02/01/2021, Resident #1 (R1) was inappropriately touched by an outside home care agency worker, Individual #1 (I1). On 04/13/2021, the complaint was referred to Community Care Licensing Divisions (CCLD) Investigations Branch (IB) and assigned to Investigator Tiffany Brunelli.
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: 03/18/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/18/2022

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 8

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: 03/18/2022

NARRATIVE

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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. Due to R1’s diagnosis of Alzheimer’s disease and under hospice care, R1 did not appear coherent to the surroundings and was unable to be interviewed.

Information obtained through Investigator Brunelli’s interviews found that a former staff, Staff #4 (S4), reported they witnessed R1’s private caregiver, I1, rub R1’s breasts. When asked what they were doing, I1 stated I1 was trying to calm R1’s anxiety. The incident was reported to management and I1 was replaced. S2 stated they did not witness any inappropriate behavior from I1. S2 stated R1 had heightened anxiety around I1.

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 S1. At 3:40pm an interview was conducted with S2. At 4:46pm the LPA reviewed medications in the medication room with S2. 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
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: 03/18/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/18/2022

LIC9099 (FAS) - (06/04)

Page: 2 of 8

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: 03/18/2022

NARRATIVE

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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. Information obtained through the course of the investigation found that there were no witnesses to the 02/01/2021 incident besides S4, and R1 was unable to provide details due to being non-verbal. Investigator Zertuche was unable to make contact with I1 as I1 had reportedly moved out of the country. However, I1 denied the allegations to I1’s supervisor, who is the At Home Care owner who provided workers to the facility. R1’s representative stated that the incident was reported to them by S5 who stated that I1 was seen by S4 rubbing R1’s breasts. R1’s representative contacted the director of At Home Care and was told that I1 caresses R1 by rubbing the back and top of chest to calm R1 when upset but denied inappropriate behaviors. I1 had previously told R1’s representative that I1 rubs R1’s back to calm R1 but not the chest area. R1’s representative did not feel the incident was malicious and may have been misconstrued. R1’s representative stated the incident seemed plausible due to R1’s issues with anxiety and added that I1 appeared to be a great caregiver and did not have any issues prior to this incident.

Based on the information obtained, the Department does not have sufficient evidence to support the above allegation. Therefore, the above allegation is deemed Unsubstantiated at this time.

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

SUPERVISOR'S NAME: Kristin Heffernan	TELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Kelly Dulek	TELEPHONE: (951) 836-3170
LICENSING EVALUATOR SIGNATURE:	DATE: 03/18/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/18/2022

LIC9099 (FAS) - (06/04)

Page: 3 of 8

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 Kelly Dulek

PUBLIC

COMPLAINT CONTROL NUMBER: 29-AS-20210409080302

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:	03/18/2022
		UNANNOUNCED	TIME BEGAN:	01:35 PM
MET WITH:	Kailey Vanderwall		TIME COMPLETED:	06:55 PM

ALLEGATION(S):

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Facility failed to follow reporting requirements

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Kelly Dulek conducted a subsequent complaint visit to the above noted facility. The purpose of the visit is to conclude an investigation regarding the above allegation initiated by LPA Lopez on 04/13/2021. LPA met with Business Office Director Kailey Vanderwall and explained the reason for the visit.

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

On 04/09/2021, the Department received a complaint which alleged the facility failed to follow reporting requirements. It was reported that Administrator Leatrice Bogoyevac and Staff #1 (S1) did not report the alleged incident of inappropriate touching of a Resident #1 (R1) that occurred on 02/01/2021.
REPORT CONTINUED ON LIC 9099-C

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: 03/18/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/18/2022

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

LIC9099 (FAS) - (06/04)

Page: 4 of 8

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: 03/18/2022

NARRATIVE

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Staff #5 (S5) received information of the alleged incident by Staff #4 (S4) and informed administrator and S1 of the alleged incident.

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. During the interview, the Administrator could not recall any incidents pertaining to Resident #1 (R1). The LPA reviewed records for three residents, including R1, and obtained pertinent copies.

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 Staff #1 (S1). At 3:40pm an interview was conducted with Staff #2 (S2). At 4:46pm the LPA reviewed medications in the medication room with S2. Copies of pertinent records were obtained.

Interviews conducted during the initial inspection on 04/13/2021 revealed that the Administrator could not recall any incidents pertaining to Resident #1 (R1). During the subsequent inspection on 06/09/2021 with further questioning, the Administrator also stated they did not submit a written incident report to the Department for the incident. Documents obtained during the course of the investigation also revealed that S4 emailed the Administrator and S1 on 02/01/2021 informing of the alleged incident. Additionally, LPA reviewed all incidents reports submitted to the Department and was not able to locate one for the alleged incident that occurred on 02/01/2021. Based on all information obtained, the above allegation “facility failed to follow reporting requirements” 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 and report reviewed with Ms. Vanderwall. A copy of the report will be emailed to Executive Director Martha Berard and mailed to the licensee.

SUPERVISOR'S NAME: Kristin Heffernan	TELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Kelly Dulek	TELEPHONE: (951) 836-3170
LICENSING EVALUATOR SIGNATURE:	DATE: 03/18/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/18/2022

LIC9099 (FAS) - (06/04)

Page: 5 of 8

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: 03/18/2022

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 03/18/2022 Section Cited CCR 87211(a)(1)(D)	1 2 3 4 5 6 7	87211 Reporting Requirements (a) Each licensee shall furnish to the licensing agency...(1) A written report shall be submitted to the licensing agency... within 7 days of the occurrence... (D) Any incident which threatens the welfare, safety or health of any resident... This requirement is not met as evidenced by:	1 2 3 4 5 6 7	Facility closed as of 10/11/2021 due to a Change of Ownership.
	8 9 10 11 12 13 14	Based on interview and record review, the licensee did not comply with the above cited section, as the Administrator admitted the facility did not submit a written incident report for the incident involving R1 that took place on 02/01/2021, which poses an immediate safety risk to residents in care.	8 9 10 11 12 13 14
Type A 03/18/2022 Section Cited CCR 87211(c)	1 2 3 4 5 6 7	87211 Reporting Requirements (c) Any suspected physical abuse that does not result in serious bodily injury...shall be reported to the local ombudsman, the corresponding licensing agency, and the local law enforcement agency within twenty-four (24) hours...Institutions Code Section 15630(b)(1) This requirement is not met as evidenced by:	1 2 3 4 5 6 7	Facility closed as of 10/11/2021 due to a Change of Ownership.
	8 9 10 11 12 13 14	Based on interview, the licensee did not comply with the above cited section, as no report was made to the local law enforcement, licensing agency or ombudsman within 24 hours, which poses an immediate health and safety risk to residents in care.	8 9 10 11 12 13 14

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: 03/18/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/18/2022

LIC9099 (FAS) - (06/04)

Page: 6 of 8

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: 03/18/2022

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 03/18/2022 Section Cited CCR 87405(d)(2)	1 2 3 4 5 6 7	87405 Administrator - Qualifications and Duties (d) The administrator shall have the qualifications specified in Sections 87405(d)(1) through (7)....(2) Knowledge of and ability to conform to the applicable laws, rules and regulations This requirement is not met as evidenced by:	1 2 3 4 5 6 7	Facility closed as of 10/11/2021 due to a Change of Ownership.
	8 9 10 11 12 13 14	Based on interview and record review, the licensee did not comply with the above cited section, as the Administrator did not report an unusual incident, which poses 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: 03/18/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/18/2022

LIC9099 (FAS) - (06/04)

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