567609903-12-15-2021-29-AS-DPEA-C9Y6TV-20211222200608

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 567609903
Report Date: 12/15/2021
Date Signed: 12/15/2021 04:27:53 PM

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
05/21/2020 and conducted by Evaluator Kasandra Lopez

PUBLIC

COMPLAINT CONTROL NUMBER: 29-AS-20200521131047

FACILITY NAME:	OAKMONT OF CAMARILLO		FACILITY NUMBER:	567609903
ADMINISTRATOR:	HERMAN L. BURGESS		FACILITY TYPE:	740
ADDRESS:	305 DAVENPORT STREET		TELEPHONE:	(805) 738-3600
CITY:	CAMARILLO	STATE: CA	ZIP CODE:	93012
CAPACITY:	0	CENSUS: 0	DATE:	12/15/2021
		UNANNOUNCED	TIME BEGAN:	10:13 AM
MET WITH:			TIME COMPLETED:	10:14 AM

ALLEGATION(S):

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Facility did not review residents assessment with family member
Facility raised fees without giving proper notice

INVESTIGATION FINDINGS:

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On 12/13/2021, and 12/15/2021, Licensing Program Analyst (LPA) KaSandra Lopez attempted to conduct a telephonic interview with Courtney Siegel, CEO of OMG II Inc. and CEO of Oakmont Management Group LLC to deliver the complaint findings regarding the above allegations. The facility closed effective 10/21/2021 and the property was re-licensed as Oakmont of Camarillo by a new licensee.

On 05/26/2020, LPA Kristin Heffernan initiated the complaint investigation telephonically with Executive Director Zehra Syed. During the inspection, LPA Heffernan interviewed the Executive Director and requested pertinent copies of records pertaining to Resident #1 (R1). During the investigation, LPA Heffernan also received copies of pertinent information from the reporting party.

LPA Lopez was reassigned to the complaint investigation on 09/18/2020.

Report continued on LIC 9099-C.

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Desaree Perera	TELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Kasandra Lopez	TELEPHONE: (818) 421-5183
LICENSING EVALUATOR SIGNATURE:	DATE: 12/15/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/15/2021

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-20200521131047

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: 12/15/2021

NARRATIVE

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On 12/09/2021, LPA Lopez conducted a Collateral inspection at Oakmont of Camarillo 565850169 and reviewed records for R1 and conducted interviews with Administrator Martha Berard and Staff #1 (S1) between 11:08 AM and 12:41 PM.

Record review revealed on 02/07/2020, R1 had Resident Assessment conducted by Staff #2 (S2) due to a change of condition. The assessment was signed by S2 and R1's responsible party. On 02/15/2020, another Resident Assessment was conducted for R1 by S2. This assessment increased R1's acuity points and billable points. This assessment was only signed by S2 and was not signed by R1 or their responsible party. The 02/15/2020 Cost of Care Communication for R1 indicates the resident had a change of condition and had an increased cost of care. The Cost of Care Communication has three method of delivery options of this document to the resident and/or the responsible party; "Presented to resident and date", "Presented to responsible party and date", and "Mailed, faxed or emailed to responsible party and date". No method of deliver is noted on this document signed by S2. The LPA reviewed and obtained a copy of R1's resident charges/payment ledger for the time period of 01/05/2020 through 12/03/2020. Record reveal beginning on 02/15/2020, R1 was billed an increased charge for care fees.

An undated letter written by Executive Director at the time, Zehra Syed stated concessions were given to R1 for a total of $4454.17 for the time period of 02/15-02/29, 03/01-03/31, 04/01-04/30, 05/01-05/31 and as of June 1, 2020 the licensee would no longer be giving concessions towards R1's care but as an act of good faith, R1's account has a fresh start.

Interviews revealed there is no record the updated 02/15/2020 assessment was presented to R1 or their responsible party, or mailed, faxed, or emailed to R1 or their responsible party, or that R1 and/or the responsible party received notice of a rate increase due to level of care change. Interviews also revealed, as of May 2020, S2 no longer worked for the licensee.

Based on the information obtained, the allegations of 'Facility did not review residents assessment with family member' and 'Facility raised fees without giving proper notice' are substantiated at this time.

A copy of the report and appeal rights were mailed to the licensee's mailing address via certified mail for signature.

SUPERVISOR'S NAME: Desaree Perera	TELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Kasandra Lopez	TELEPHONE: (818) 421-5183
LICENSING EVALUATOR SIGNATURE:	DATE: 12/15/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/15/2021

LIC9099 (FAS) - (06/04)

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Control Number 29-AS-20200521131047

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: 12/15/2021

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 12/13/2021 Section Cited HSC 1569.657(a)	1 2 3 4 5 6 7	Rate increase due to change in level of resident care; notice (a) For any rate increase due to a change in the level of care of the resident, the licensee shall provide the resident and the resident’s representative, if any, written notice of the rate increase within two business days after initially providing services at the new level of care......	1 2 3 4 5 6 7	Record review revealed the resident was reimbursed for charges. The facility is now closed. Plan of correction is cleared.
	8 9 10 11 12 13 14	This requirement is not met as evidenced by: Based on interview and record review, the licensee did not comply with the section cited above as their is no proof R1 or the responsible party received written notice of the rate increase which is a potential personal rights risk to residents in care.	8 9 10 11 12 13 14
Type B 12/13/2021 Section Cited CCR 87463(c)	1 2 3 4 5 6 7	87463 Reappraisals(c) The licensee shall arrange a meeting with the resident, the resident’s representative, if any,... if any, when there is significant change in the resident’s condition, or once every 12 months, whichever occurs first, as specified in Section 87467, Resident Participation in Decision Making.	1 2 3 4 5 6 7	The facility is closed. Plan of correction is cleared.
	8 9 10 11 12 13 14	This requirement is not met as evidenced by: Based on record review and interview, the licensee failed to comply with the section cited above there is no record of an arrangement for a meeting of the 02/15/2020 reappraisal with R1 and their responsible party which poses a personal rights 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: Desaree Perera	TELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Kasandra Lopez	TELEPHONE: (818) 421-5183
LICENSING EVALUATOR SIGNATURE:	DATE: 12/15/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/15/2021

LIC9099 (FAS) - (06/04)

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