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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 567609903
Report Date: 12/20/2021
Date Signed: 12/20/2021 04:07:50 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
01/05/2021 and conducted by Evaluator Kasandra Lopez
COMPLAINT CONTROL NUMBER: 29-AS-20210105083035
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:
12/20/2021
UNANNOUNCEDTIME BEGAN:
03:54 PM
MET WITH:Susan McPhersonTIME COMPLETED:
04:00 PM
ALLEGATION(S):
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Staff did not clean resident room
Room has odor
Food service inadequate
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) KaSandra Lopez conducted telephonic interview with Licensee Representative Susan McPherson to deliver the findings regarding the above allegations. The facility closed effective 10/21/2021 and the property was re-licensed under a new licensee.

The allegations allege on 12/20/2020, R1 was found by staff to have soiled their clothing, the floor, and bed with loose bowel movements. R1's family decided to have R1 hospitalized on 12/20/2020, and when R1 returned back to the facility on 12/31/2020, R1's room was found to have not been cleaned since they were hospitalized and having a strong odor. Also when R1 returned back from the hospital it took two hours for R1 to receive a meal.

On 01/08/2021, LPA Lopez initiated a complaint tele-investigation and conducted a telephone interview with Administrator Leatrice Bogoyevac. The LPA also conducted an additional telephonic staff interview and observed the bedroom of Resident #1 (R1) though a video call. 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: 12/20/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/20/2021
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 3
Control Number 29-AS-20210105083035
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: 12/20/2021
NARRATIVE
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Interviews with the Administrator and Staff #1 (S1) on 01/08/2021, confirmed when R1 returned from the hospital their room had not been cleaned since before R1 was hospitalized. Interviews also revealed, R1's soiled bedding was not changed until the next day after they came home from the hospital. Based on this information, the allegations of 'Staff did not clean resident room' and 'Room has odor' are deemed substantiated at this time.

Interviews with the Administrator and S1 confirmed that on 01/01/2021 there was at least an hour delay of R1 receiving a meal which is not a normal delivery time. S1 stated they ended up delivering R1 their meal as the kitchen did not delivered R1's meal timely. Based on this information, the allegation of 'Food service inadequate' is substantiated at this time.

Exit interview and report reviewed with Susan McPherson. 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: 12/20/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/20/2021
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 29-AS-20210105083035
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: 12/20/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
12/13/2021
Section Cited
CCR
87468.1(a)(2)
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87468.1 Personal Rights of Residents in All Facilities (a) (2) To be accorded safe, healthful and comfortable accommodations, furnishings and equipment.

This requirement is not met as evidenced by:
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The room and bedding were cleaned 01/01/2021. Facility is now closed. Plan of correction is cleared.
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Based on interviews, the licensee failed to comply with the section cited above as the facility failed to clean R1's room and bedding timely, and R1 did not get a meal timely which poses an immediate personal rights and health risk to R1 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: 12/20/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/20/2021
LIC9099 (FAS) - (06/04)
Page: 3 of 3