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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 09:49:38 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
07/19/2021 and conducted by Evaluator Kelly Dulek
PUBLIC
COMPLAINT CONTROL NUMBER: 29-AS-20210719161157
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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Staff video recorded resident without permission
Staff posted a video of resident on social media
Staff mocked resident
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Kelly Dulek conducted an unannounced subsequent complaint inspection at the facility today, with the purpose of delivering findings for the above listed allegations. The LPA arrived at 01:35PM and met with Business Office Director Kailey Vanderwall. The LPA informed the Business Office Director of the reason for today's inspection. Entrance interview conducted.

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.

During today's visit, LPA Dulek, along with Business Office Director, conducted a facility tour at 1:40PM. During a previous visit on 07/28/2021, LPA Dulek had conducted an interview with Regional Executive Director Specialist, Regional Health Services Director and Executive Director at 12:55PM, conducted staff
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 4
Control Number 29-AS-20210719161157
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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interviews from 2:28PM to 3:20PM and gathered copies of documents pertinent to the investigation. During a previous Case Management visit on 7/19/2021, LPA Dulek had conducted staff and resident interviews at 7:15AM, 7:26AM, 7:51AM, and 8:14AM. On 7/19/2021, LPA toured the Memory Care unit at 7:15AM. The following was then concluded:

An incident report was received in the Woodland Hills Regional Office via fax on 07/15/2021. The report indicated that on 07/13/2021 the facility was made aware of a social media video of Resident #1 (R1). The video was recorded in R1’s room during the evening on 07/12/2021 and posted to social media by Staff #1 (S1). Interview revealed that former staff, S1, had video recorded R1 in R1’s room. Review of R1’s facility Admission Agreement and Resident Photo Consent revealed that while R1’s representative did give authorization to Oakmont Senior Living to use R1’s photographs taken during events and activities to display in the community or on the community’s social media pages for advertising purposes. However, the video in question was found to be posted to S1’s personal social media. Further, Oakmont staff policy indicates “no one is permitted to photograph, videotape, or voice record a resident without their consent.” Interview and record review revealed that no written authorization was given for S1 to video record R1. Therefore, based on interview and record review, the allegation that “staff video recorded resident without permission is deemed” SUBSTANTIATED at this time.

The incident report the facility provided to the Woodland Hills Regional Office on 07/15/2021 indicated facility was made aware of a snap chat video of R1. Interview revealed that an unrelated citizen of Camarillo had seen the video on their social media on 07/12/2021 and the citizen’s family member reported to the facility on 07/13/2021. The video was shown to facility staff on 07/13/2021 and facility staff acknowledged viewing the video and it’s contents. Based on interview and observation, the allegation that “staff posted a video of resident on social media” is deemed SUBSTANTIATED at this time.

LPA interviewed staff, and R1 with regard to the complaint allegations. Interview revealed that facility staff were laughing while present in R1’s room, talking, and saying things to get a reaction from R1. Observing staff stated they “didn’t feel comfortable with it” and that “(R1) did not like it, was getting upset.” Resident interview revealed that staff are “not particularly nice.” Therefore, based on interview, the allegation that “staff mocked resident” is deemed SUBSTANTIATED at this time.

Pursuant to Title 22 CA Code of Regulations, the following deficiencies were cited (refer to LIC 9099-D). Exit interview conducted. A copy of the report was provided via email.

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 4
Control Number 29-AS-20210719161157
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
87468.1(a)
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87468.1 Personal Rights of Residents in All Facilities 1) To be accorded dignity in their personal relationships with staff, residents, and other persons.

This requirement is not met as evidenced by:
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Training was provided for all staff on 7/20/2021 and 7/28/2021. Facility was closed due to a Change of Ownership effective 10/11/2021.
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Based on interview and observation, the licensee did not comply with the above section, as facility staff took video of and mocked R1, which poses an immediate personal rights risk to residents in care.
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Type A
03/18/2022
Section Cited
CCR
87468.1(a)(3)
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87468.1 Personal Rights of Residents in All Facilities (a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (3) To be free from punishment, humiliation...functions such as eating, sleeping, or elimination.
This requirement was not met as evidenced by:
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Training was provided for all staff on 07/20/2021 and 07/28/2021. Facility was closed due to a Change of Ownership effective 10/11/2021.
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Based on interview and observation, the licensee did not comply with the above section, as facility staff took video of and posted video to social media, which poses an immediate personal rights 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 4
Control Number 29-AS-20210719161157
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
87507(f)
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87507 Admission Agreements (f) The licensee shall comply with all applicable terms and
conditions set forth in the admission agreement, including all modifications and attachments.

This requirement is not met as evidenced by:
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Training was provided to all staff on 07/20/2021 and 07/28/2021. Facility was closed due to a Change of Ownership effective 10/11/2021.
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Based on record review and interview, the licensee did not comply with the above section, as staff videoed R1 without permission, which poses an immediate safety and personal rights 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: 4 of 4