567609903-3-2-2023-29-AS-DPEA-CS3UNF-20230522154349

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 567609903
Report Date: 03/02/2023
Date Signed: 03/02/2023 06:11:09 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
06/29/2021 and conducted by Evaluator Kelly Dulek

COMPLAINT CONTROL NUMBER: 29-AS-20210629091537

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:	03/02/2023
		UNANNOUNCED	TIME BEGAN:	12:10 PM
MET WITH:	Bradlee Foerschner		TIME COMPLETED:	06:15 PM

ALLEGATION(S):

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Staff do not respond timely to a resident's alerts while in care
Staff are not property assisting a resident while in care

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 12:10PM and met with Executive Director (ED) Bradlee Foerschner. The LPA informed the ED 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 Dulek 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 inspection conducted on 07/01/2021, LPAs Martha Guzman Chavez and Kelly Dulek conducted
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: 03/02/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/02/2023

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

LIC9099 (FAS) - (06/04)

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Control Number 29-AS-20210629091537

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: 03/02/2023

NARRATIVE

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an interview with Regional Executive Director Specialist at 12:25PM, toured the facility at 12:34PM, conducted staff interviews at 1:40PM and 2:35PM, and gathered copies of documents pertinent to the investigation. The following was then determined:

Regarding the allegation "staff do not respond timely to a resident's alerts while in care;"
It was alleged that particularly during the overnight shift, Resident #1 (R1)'s call pendant is not being responded to timely, resulting in R1 being unable to transfer to the commode. The complaint further indicates that R1 has called 9-1-1 when the facility staff did not respond to R1's request for assistance timely. Office of Emergency Service records were reviewed and reflect that R1 called 9-1-1 on the following dates and times: 05/14/2021 at 11:29PM, 06/02/2021 at 07:03AM, 06/21/2021 at 11:24PM, 06/25/2021 at 12:38AM, 06/29/2021 at 04:05AM. Interview with R1 confirmed that those phone calls were made when requests for assistance remained unanswered. LPA reviewed facility logs for pendant calls and response times for R1 for the week of June 25-June 30, 2021. Pendant response time varied between 10 seconds to 8 hours, 36 minutes, and 14 seconds. In total, there were 11 (eleven) times the response time was greater than 10 minutes. Additionally, record review revealed on 06/26/2021, R1 began calling at 02:13AM and called for assistance 14 (fourteen) times before R1 fell. Interview revealed that there are 2 (two) staff who work in Assisted Living during the overnight shift, one caregiver and one medication technician. Staff interview revealed that depending on how busy the staff are when the call comes in determines how long a resident waits for assistance. Typically, staff try to respond as soon as possible but the goal is to respond within 10 (ten) minutes. Based on interview and record review, the allegation "staff do not respond timely to a resident's alerts while in care" is deemed SUBSTANTIATED at this time.

Regarding the allegation "staff are not properly assisting a resident while in care:"
It was alleged that when R1 needs to be transferred to the commode during the overnight shift, staff are not responsive to R1's calls for assistance. Record review revealed that R1 does require transfer assistance. Interview revealed that R1 has a bedside commode to ensure night time toileting needs are met and that R1 typically calls for assistance to transfer to the commode when needed during the overnight shift. During the daytime hours Monday through Friday, R1 has a private caregiver who assists R1 with transfers, but during the overnight shift and weekends, R1 relies on facility staff assisting with transfers, which is reflected in R1's care assessment. As established above, R1 calls during the overnight shift and response times reviewed reflected 11 (eleven) times R1's response time was greater than 10 minutes between 06/25/2021 and
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: 03/02/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/02/2023

LIC9099 (FAS) - (06/04)

Page: 2 of 4

Control Number 29-AS-20210629091537

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: 03/02/2023

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32	06/29/2021. Based on interview and record review, the allegation "staff are not properly assisting a resident while in care 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 was provided.

SUPERVISOR'S NAME: Kristin Heffernan	TELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Kelly Dulek	TELEPHONE: (951) 836-3170
LICENSING EVALUATOR SIGNATURE:	DATE: 03/02/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/02/2023

LIC9099 (FAS) - (06/04)

Page: 3 of 4

Control Number 29-AS-20210629091537

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: 03/02/2023

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 03/02/2023 Section Cited CCR 87464(f)(4)	1 2 3 4 5 6 7	87464 Basic Services (f) Basic services shall at a minimum include: (4) Personal assistance and care as needed by the resident and as indicated in the pre-admission appraisal, with those activities of daily living...87608, Postural Supports. 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 interview and record review, the licensee did not comply with the above cited section, as R1 used their call light for assistance in transferring and the response time was greater than 10 minutes 11 times in a 5 day period, 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: 03/02/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/02/2023

LIC9099 (FAS) - (06/04)

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