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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 567609903
Report Date: 09/22/2022
Date Signed: 09/22/2022 02:05:16 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
05/11/2021 and conducted by Evaluator Kelly Dulek
PUBLIC
COMPLAINT CONTROL NUMBER: 29-AS-20210511172206
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:
09/22/2022
UNANNOUNCEDTIME BEGAN:
11:35 AM
MET WITH:Bradlee FoershcnerTIME COMPLETED:
02:05 PM
ALLEGATION(S):
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Facility staffing is not adequate to meet residents needs.
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 11:35 AM and met with Executive Director Bradlee Foerschner. The LPA informed the Executive Director 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 a previous visit which took place on 05/12/2021 LPA Dulek conducted a facility tour with Business Office Manager Kailey Vanderwall at 10:08AM, an interview with the Administrator Lea Bogoyevac at 10:28AM, interviewed staff at 10:08AM and again from 12:02PM to 4:40PM and gathered copies of documents pertinent to the investigation. 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: 09/22/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/22/2022
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 3
Control Number 29-AS-20210511172206
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: 09/22/2022
NARRATIVE
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It was alleged that on Sunday 05/09/2021, there was insufficient staffing at the facility. LPA spoke with staff who were scheduled to work that day. Review of staff schedule showed that for the day shift, AL had one med tech scheduled and one caregiver scheduled. Memory Care had 2 caregivers scheduled as well as 1 med tech scheduled during the day shift. During the pm shift, there was no caregiver scheduled in AL and one med tech scheduled. For the Memory Care side during the pm shift, there were 3 caregivers scheduled and one med tech scheduled. However, interview revealed that staff had called out for their shifts. Staff interviews revealed the facility is understaffed, many staff call out and remaining staff are asked to work double shifts. Staff interview revealed that beginning at 06:00AM on 05/09/2021 for about 2 and 1/2 hours there was only one caregiver present in memory care. There was a med tech present, but only one caregiver. During this time period, one resident sustained a fall, resulting in injury and emergency services needed. Interview revealed that in memory care there are 2 residents that require a 2-person assist and there were 16 residents in Memory Care at that time. Interview also revealed that there was only a med tech present in Assisted Living during the day shift. One caregiver was present from 8:00AM until 2:00PM on 05/09/2021, but at 2:00PM, the caregiver left and the med tech was alone with the residents. Interview revealed a maintenance person remained at the facility to assist the residents, however the maintenance staff is not trained for caregiving needs. There are 3 or 4 residents in Assisted Living that require a 2-person assist. Therefore, based on interview and record review, the allegation that "Facility staffing is not adequate to meet residents needs" 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. 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: 09/22/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/22/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 29-AS-20210511172206
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: 09/22/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
09/22/2022
Section Cited
CCR
87411(a)
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87411 (a) Facility personnel shall at all times be sufficient in numbers... to provide the services necessary to meet resident needs...facility require such additional staff for the provision of adequate services.
This requirement is not met as evidenced by:
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Due to a Change of Ownership which took place on 10/11/2021, the facility is closed.
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Based on interview and staff schedule review, on 05/09/2021, there were 60 total residents, 5-7 of which require a 2-person assist and there were only 2 caregivers present at the facility, which poses 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: 09/22/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/22/2022
LIC9099 (FAS) - (06/04)
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