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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 567609903
Report Date: 03/18/2022
Date Signed: 03/21/2022 09:45:25 AM



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
07/08/2021 and conducted by Evaluator Kelly Dulek
PUBLIC
COMPLAINT CONTROL NUMBER: 29-AS-20210708160136
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:
03/18/2022
UNANNOUNCEDTIME BEGAN:
01:35 PM
MET WITH:Kailey VanderwallTIME COMPLETED:
06:55 PM
ALLEGATION(S):
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Neglect/Lack Supervision: Resident #3 (R3) sustained unexplained bruising
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Kelly Dulek conducted a subsequent complaint visit to deliver findings for the above allegation. 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 07/08/2021, the Department received a complaint regarding an allegation of Neglect/Lack of Supervision. It was alleged that facility Resident #3 (R3) sustained unexplained bruising. The complaint was referred to Community Care Licensing (CCL) Investigations Branch (IB) and assigned to Investigator Peter Zertuche.

Report Continued on LIC 9099-C
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Kristin HeffernanTELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Kelly DulekTELEPHONE: (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 10
Control Number 29-AS-20210708160136
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 07/09/2021, from 11:18am to 2:45pm, Licensing Program Analyst (LPA) KaSandra Lopez conducted an unannounced initial 10-day complaint inspection at the facility. LPA Lopez met with Interim Administrator, Regional Executive Director Specialist Krystal Jenkins at 11:21am and explained the reason for the inspection. During the inspection, the LPA conducted an interview with Ms. Jenkins beginning at 11:21am. At 11:45am an interview was conducted with Staff #1 (S1) and at 12:15pm an interview was conducted with Resident #1 (R1). At 12:10pm the LPA conducted a brief tour of the facility. Beginning at 12:22pm, the LPA reviewed facility records and obtained pertinent copies. No immediate health and safety concerns were observed. The LPA determined further investigation was needed.

On 07/12/2021, at approximately 4:30pm, Investigator Zertuche contacted Detective Ryan Clark of the Ventura County Sheriff’s Department, who forwarded a copy of the initial police report. The reporting party reported an incident with R3 on an unknown date in 2021. It was reported that R3 fell during the night sustaining red marks and bumps to face. Included with the report were photos of R3’s injuries showing light swelling to left eye and minor red marks to the left side of face.

On 07/14/2021, at approximately 8:30am, Detective Clark emailed Investigator Zertuche a copy of a supplemental police report documenting an interview with R3’s representative. R3’s representative reported R3 was placed at the facility due to progression of Alzheimer’s as R3 became aggressive and confused as to who people were. R3 was placed in the facility from February 2020 to June 2021. R3’s representative stated there were several incidents where R3 fell and sustained injures. R3’s representative also reported that R3 was aggressive and required additional medications.

On 08/12/2021, at approximately 3:00pm, Investigator Zertuche conducted interviews with former facility staff members; on 08/13/2021, at approximately 11:00am, with R3’s representative; on 08/17/2021, from approximately 10:00am to 1:00pm, conducted a joint interview with Detective Clark with facility staff.

R3’s records indicate a history of falls and wandering behaviors. After numerous falls, there continued to be further incidents, the last one being a fall on 04/13/2021 where R3 was found outside, at 6:10am, lying on the ground sustaining injuries to face. It is unknown how long R3 was outside on the ground before being found as there were no witnesses to the incident. R3 is non-verbal and was unable to provide details. At 6:17am
Report Continued on LIC 9099-C
SUPERVISOR'S NAME: Kristin HeffernanTELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Kelly DulekTELEPHONE: (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: 4 of 10
Control Number 29-AS-20210708160136
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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paramedics were called and assessed R3’s vital signs. R3’s representative refused to have R3 transported to hospital. At 7:50am, R3 was given pain medication for left arm pain and pain on left side of face. Staff attempted to clean R3’s face, but R3 refused. Based on the information obtained, there is sufficient evidence to support the allegation, therefore the above allegation is deemed SUBSTANTIATED at this time.

Pursuant to Title 22, California Code of Regulations, the following deficiency is cited (refer to LIC 9099-D).

Exit interview conducted, civil penalty assessed, appeal rights discussed, and a copy of this report issued.
SUPERVISOR'S NAME: Kristin HeffernanTELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Kelly DulekTELEPHONE: (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 10
Control Number 29-AS-20210708160136
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
87464(f)(1)
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87464(f)(1) Basic Services. (f) Basic services shall at a minimum include: (1) Care and supervision as defined in Section 87101(c)(3) and Health and Safety Code Section 1569.2(c).

This requirement is not met as evidenced by:
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Facilty underwent a Change of Ownership; this facility was closed effective 10/11/2021.
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Based on interviews and records review, the licensee did not comply with the section cited above. (R1) was not provided the proper supervision to ensure R1’s safety. R1 had a history of falls and wandering behavior, which led to sustained injuries to face from a 04/13/2021 fall, which posed an immediate health and safety risk to residents 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: Kristin HeffernanTELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Kelly DulekTELEPHONE: (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: 3 of 10
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
07/08/2021 and conducted by Evaluator Kelly Dulek
PUBLIC
COMPLAINT CONTROL NUMBER: 29-AS-20210708160136

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:
03/18/2022
UNANNOUNCEDTIME BEGAN:
01:35 PM
MET WITH:Kailey VanderwallTIME COMPLETED:
06:55 PM
ALLEGATION(S):
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Neglect/Lack Supervision: Resident #2 (R2) 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 deliver findings for the above allegation. 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 07/08/2021, the Department received a complaint regarding an allegation of Neglect/Lack of Supervision. It was alleged that on 02/01/2021, Resident #2 (R2) was inappropriately touched by an outside home care agency worker, Individual #1 (I1). This allegation was previously addressed on Complaint Control #29-AS-20210409080302. The complaint was referred to Community Care Licensing (CCL) Investigations Branch
Report Continued on LIC 9099-C
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Kristin HeffernanTELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Kelly DulekTELEPHONE: (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: 5 of 10
Control Number 29-AS-20210708160136
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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(IB) and assigned to Investigator Peter Zertuche.

On 07/09/2021, from 11:18am to 2:45pm, Licensing Program Analyst (LPA) KaSandra Lopez conducted an unannounced initial 10-day complaint inspection at the facility. LPA Lopez met with Interim Administrator, Regional Executive Director Specialist Krystal Jenkins at 11:21am and explained the reason for the inspection. During the inspection, the LPA conducted an interview with Ms. Jenkins beginning at 11:21am. At 11:45am an interview was conducted with Staff #1 (S1) and at 12:15pm an interview was conducted with Resident #1 (R1). At 12:10pm the LPA conducted a brief tour of the facility. Beginning at 12:22pm, the LPA reviewed facility records and obtained pertinent copies. No immediate health and safety concerns were observed. The LPA determined further investigation was needed.

On 07/12/2021, at approximately 4:30pm, Investigator Zertuche contacted Detective Ryan Clark of the Ventura Cunty 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 S1.

On 08/12/2021, at approximately 3:00pm, Investigator Zertuche interviewed S2 and Staff #3 (S3); 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 S2, and R2 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. R2’s representative stated that the incident was reported to them by S3 who stated that I1 was seen by S2 rubbing R2’s breasts. R2’s representative contacted the director of At Home Care and was told that I1 caresses R2 by rubbing the back and top of chest to calm R2 when upset but denied inappropriate behaviors. I1 had previously told R2’s representative that he rubs R2’s back to calm R2 but not the chest area. R2’s
Report Continued on LIC 9099-C
SUPERVISOR'S NAME: Kristin HeffernanTELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Kelly DulekTELEPHONE: (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: 6 of 10
Control Number 29-AS-20210708160136
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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representative did not feel the incident was malicious and may have been misconstrued. R2’s representative stated the incident seemed plausible due to R2’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, appeal rights and copy of report given.
SUPERVISOR'S NAME: Kristin HeffernanTELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Kelly DulekTELEPHONE: (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: 7 of 10
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
07/08/2021 and conducted by Evaluator Kelly Dulek
COMPLAINT CONTROL NUMBER: 29-AS-20210708160136

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:
03/18/2022
UNANNOUNCEDTIME BEGAN:
01:35 PM
MET WITH:Kailey VanderwallTIME COMPLETED:
06:55 PM
ALLEGATION(S):
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Neglect/Lack Supervision: Facility staff allowed Resident #4 (R4) to choke without intervention.
Neglect/Lack of Supervision: Facility staff did not seek timely medical attention for R4 during choking incident.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Kelly Dulek conducted a subsequent complaint visit to deliver findings for the above allegation. 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 07/08/2021, the Department received a complaint regarding allegations of Neglect/Lack of Supervision. It was alleged that facility staff allowed Resident #4 (R4) to choke without intervention and
facility staff did not seek timely medical attention for R4 during choking incident. The complaint was referred to Community Care Licensing (CCL) Investigations Branch (IB) and assigned to Investigator Peter Zertuche.
REPORT CONTINUED ON LIC 9099-C
Unfounded
Estimated Days of Completion:
SUPERVISOR'S NAME: Kristin HeffernanTELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Kelly DulekTELEPHONE: (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: 8 of 10
Control Number 29-AS-20210708160136
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 07/09/2021, from 11:18am to 2:45pm, Licensing Program Analyst (LPA) KaSandra Lopez conducted an unannounced initial 10-day complaint inspection at the facility. LPA Lopez met with Interim Administrator, Regional Executive Director Specialist Krystal Jenkins at 11:21am and explained the reason for the inspection. During the inspection, the LPA conducted an interview with Ms. Jenkins beginning at 11:21am. At 11:45am an interview was conducted with Staff #1 (S1) and at 12:15pm an interview was conducted with Resident #1 (R1). At 12:10pm the LPA conducted a brief tour of the facility. Beginning at 12:22pm, the LPA reviewed facility records and obtained pertinent copies. No immediate health and safety concerns were observed. The LPA determined further investigation was needed.

On 07/12/2021, at approximately 4:30pm, Investigator Zertuche contacted Detective Ryan Clark of the Ventura County Sheriff’s Department, who forwarded a copy of the initial police report. The reporting party reported an incident where R4 choked on a piece of steak. The reporting party was not present during the incident but heard from staff that R4 was turning blue and purple while staff panicked and watched for five (5) minutes before helping and calling 9-1-1.

On 07/14/2021, at approximately 3:30pm, Investigator Zertuche contacted the Ventura County Coroner’s office. The investigator confirmed there was no autopsy conducted on R4 as there were no suspicious circumstances leading to the death and the cause of death was listed as cardiac arrest. Date of death was listed as 08/30/2020 at 12:19am.

On 08/12/2021, at approximately 3:00pm, Investigator Zertuche conducted interviews with former staff; and on 08/17/2021, from approximately 10:00am to 3:00pm, with staff and residents. Additionally,
on 08/17/2021, at approximately 2:30pm, Investigator Zertuche received a copy of the Ventura County Medical Examiner’s Investigative Report from Detective Clark; and on 08/30/2021, the investigator received the Ventura County Fire Department 9-1-1 call report.

R4’s Physician Report dated 04/23/2020, lists the diagnosis as chronic kidney disease, stage 4 and non-rheumatic aortic (valve) stenosis. R4 was listed as non-ambulatory with a special diet where R4 self-managed a carbohydrates-controlled diet. There was nothing noted regarding a choking risk.

Report Continued on LIC 9099-C
SUPERVISOR'S NAME: Kristin HeffernanTELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Kelly DulekTELEPHONE: (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: 9 of 10
Control Number 29-AS-20210708160136
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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According to the Ventura County Medical Examiner’s Investigative Report, there was no airway obstruction noted with laryngoscopy. R4 also had a Do Not Resuscitate (DNR) on file. Additionally, it was noted that food was not observed in or had been removed from R4’s airway. Upon arrival, paramedics observed R4 lying on the floor and staff reported R4 had choked while eating dinner. Additionally, according to medical records, there was no evidence of choking as there was no food in the mouth or airway. The cause of death was listed as cardiac arrest and there was no autopsy performed. Staff members reported they immediately went to the scene after hearing the radio call on 08/29/2020 at 5:43pm. The 9-1-1 call report confirmed that paramedics were called on 08/29/2020 at approximately 5:44pm. There were two residents with R4 that reported staff and paramedics arrived immediately and had no concerns with the care provided.

Based on the information obtained, there was no evidence to support the allegations, therefore, the above allegations are deemed unfounded at this time. A finding of unfounded means that the allegation is either false, could not have happened, and/or is without a reasonable basis.

Exit interview conducted and a copy of this report was reviewed and issued.
SUPERVISOR'S NAME: Kristin HeffernanTELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Kelly DulekTELEPHONE: (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: 10 of 10