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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 567609936
Report Date: 08/24/2023
Date Signed: 08/24/2023 09:21:00 AM

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
05/18/2021 and conducted by Evaluator Jeannette Olson
COMPLAINT CONTROL NUMBER: 29-AS-20210518134750
FACILITY NAME:OAKMONT OF RIVERPARKFACILITY NUMBER:
567609936
ADMINISTRATOR:LIBHART, JILLFACILITY TYPE:
740
ADDRESS:901 TOWN CENTER DRIVETELEPHONE:
(805) 940-0390
CITY:OXNARDSTATE: CAZIP CODE:
93036
CAPACITY:0CENSUS: 0DATE:
08/24/2023
UNANNOUNCEDTIME BEGAN:
08:26 AM
MET WITH:TIME COMPLETED:
09:30 AM
ALLEGATION(S):
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Staff failed to seek medical attention for residents in a timely manner after a fall
Staff spoke inappropriately to resident
Staff failed to treat resident with dignity and respect
Insufficient staffing to meet the residents' needs
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Olson delivered final findings for the above allegations via certified mail, due to the facility closed due to a change of ownership effective 10/20/2021.

On 05/18/2021, the Department received a complaint regarding allegations of Neglect/Lack of Supervision. It was alleged that while under facility care, staff failed to seek medical attention for residents in a timely manner; staff spoke inappropriately to resident; staff failed to treat resident with dignity and respect; and insufficient staffing to meet the residents' needs.

On 05/19/2021, between 11:25am and 7:15pm, Licensing Program Analyst (LPA) JoAnn Rosales conducted the initial 10-day complaint visit. During the visit LPA Rosales toured the facility with staff, reviewed resident records, obtained copies of pertinent documents and interviewed staff. The LPA determined further investigation was required. On 07/16/2021, between 10:33am and 4:49pm, and on 09/28/2021, between 9:55am and 4:45pm, LPA Rosales conducted subsequent complaint visits to continue the investigation. Continued on 9099-C
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Kelly BurleyTELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Jeannette OlsonTELEPHONE: (805) 635-4718
LICENSING EVALUATOR SIGNATURE:

DATE: 08/24/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/24/2023
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 7
Control Number 29-AS-20210518134750
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 RIVERPARK
FACILITY NUMBER: 567609936
VISIT DATE: 08/24/2023
NARRATIVE
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The LPA toured the facility with the Administrator and interviewed random residents and staff. The LPA determined further investigation was required. On 10/18/2022, the Department referred the case to the Community Care Licensing (CCL) Investigations Branch (IB) and the case was assigned to Investigator Edward Hector to further investigate the allegation of untimely medical attention after falls that resulted in injury.

On 05/19/2021, from 1:47pm to 5:14pm, LPA Rosales conducted interviews with staff; on 07/21/2021, from 1:56pm to 3:08pm, with residents and staff; on 09/24/2021, at 4:18pm, with Resident #3 (R3); and on 09/28/2021, from 2:06pm to 2:58pm with residents and staff. On 10/27/2022, at 5:17pm, Investigator Hector interviewed R1’s resident representative; on 11/17/2022, at 1:30pm, with R2’s resident representative; and on 11/17/2022, at 12:30pm, with the facility administrator. In addition, the investigator reviewed medical records and facility file information related to R1 and R2.

On the allegation “Staff failed to seek medical attention for residents in a timely manner after a fall.” The investigation revealed that on 02/11/2021, R1 sustained an unwitnessed fall and complained of pain in their neck and back. The facility contacted R1’s doctor on 2/11/2021 via fax stating R1 was complaining of neck and back pain after the unwitnessed fall, and would like to schedule an appointment. The next day, 02/12/2021, after a zoom call with R1’s physician, R1 was taken to the hospital for evaluation at 5:02pm. The facility staff advised the medical staff that R1 was on the floor after the fall, for an unknown amount of time. It was noted during the assessment that R1 tested positive for COVID-19. R1 was admitted to the hospital on 02/13/2021 for further tests. A CT scan revealed R1 had sustained an acute nondisplaced C2 fracture (neck fracture). R1 was fitted with an Aspen neck collar to wear for 6 weeks to assist in rehabilitation. R1 was discharged on 02/19/2021 to a Skilled Nursing Facility.

On 02/13/2021, R2 had a trip and fall at the facility. R2 was taken to the hospital later that day at 3:09pm. R2 stated they tripped on the carpet and fell forward. R2 had no bruising or abrasions noted to head. The hospital staff documented that R2 had sternal pain after a mechanical fall. A CT scan revealed R2 had sustained a spinal fracture of T12 vertebra (broken back). Neurosurgery was consulted and recommended a TLSO (Thoraco Lumbo Sacral Orthosis) brace for R2. R2 was discharged to a skilled nursing facility. Interviews revealed that the AM staff and the PM staff would not always write the incidents in their shift report, and did not call for emergency medical services immediately on some occasions. Staff interviewed reported they did not call for emergency medical services when R1 fell at the facility. Continued on 9099-C (pg3)
SUPERVISOR'S NAME: Kelly BurleyTELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Jeannette OlsonTELEPHONE: (805) 635-4718
LICENSING EVALUATOR SIGNATURE:

DATE: 08/24/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/24/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 7
Control Number 29-AS-20210518134750
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 RIVERPARK
FACILITY NUMBER: 567609936
VISIT DATE: 08/24/2023
NARRATIVE
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Although staff called for emergency medical services on the first fall R2 sustained, they did not call for emergency medical services after R2 sustained their second fall. Based on the information obtained there is sufficient evidence to support the allegation “Staff failed to seek medical attention for residents in a timely manner.” Therefore, the allegation is deemed substantiated at this time.

On the allegations “Staff spoke inappropriately to resident” and the “Staff failed to treat resident with dignity and respect.” In February 2021, R3 experienced severe diarrhea and informed the morning shift staff. The staff changed R3 by standing them up with their depends and chucks underneath them. R3 then had another episode of diarrhea. The staff then reached for R3’s perfume and sprayed R3’s private area and rectum which was already scalded from the diarrhea. R3 told the staff to “stop, it’s hurting and it’s burning”. The staff told R3 “all the residents get the spray.” The staff told R3 “you are being dramatic” and “nobody wants to come help you”. R3 stated they felt very inhumanely treated and there were no repercussions for the mistreatment. R3 had redness, pain, and small blisters. R3 stated they had to lay on their side, because sitting was painful. On 02/13/2021, the facility medication technician faxed R3’s physician to inform that R3 was experiencing “irritation on bottom, parts of skin are raised in texture and has small blisters, very itchy, skin slightly red, slight pain as well”. The physician ordered a prescription of Calmoseptine ointment twice a day for 7 days and advised to “change diapers more frequently and change positions often to offload pressure on affected area as well.” Interviews with staff and administrator also confirmed they were aware of this incident. Based on the information obtained there is sufficient evidence to support the allegations “Staff spoke inappropriately to resident” and the “Staff failed to treat resident with dignity and respect”. Therefore, both allegations are deemed substantiated at this time.

On the allegation “Insufficient staffing to meet the residents' needs.” The administrator stated there were no staff schedules available to review except for April and May 2021. Several staff interviewed indicated there were staffing shortages and at times there would be a two-hour gap from 1:00pm to 3:00pm where they would only have 1 caregiver and 1 medication technician on the floor for the whole building. During that time, there were two residents who required two person staff assistance, which indicates a lack of staffing. Based on the information obtained there is sufficient evidence to support the allegation “Insufficient staffing to meet the residents' needs”. Therefore, the allegation is deemed substantiated at this time.

Pursuant to Title 22, California Code of Regulations, the following deficiencies are cited (refer to LIC 9099-D)
Appeal rights and a copy of this report was mailed.
SUPERVISOR'S NAME: Kelly BurleyTELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Jeannette OlsonTELEPHONE: (805) 635-4718
LICENSING EVALUATOR SIGNATURE:

DATE: 08/24/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/24/2023
LIC9099 (FAS) - (06/04)
Page: 3 of 7
Control Number 29-AS-20210518134750
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 RIVERPARK
FACILITY NUMBER: 567609936
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/24/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
08/24/2023
Section Cited
CCR
87465(g)
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87465(g) Incidental Medical and Dental Care The licensee shall immediately telephone 9-1-1 if an injury or other circumstance has resulted in an imminent threat to a resident’s health including, but not limited to, an apparent life-threatening medical crisis...This requirement is not met as evidenced by:
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Facility closed, change of ownership effective 10/20/2021.
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Based on interviews, the licensee did not comply with the section cited above when the facility did not seek emergency medical attention for R1 and R2, which posed an immediate health and safety risk to residents in care.
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Type A
08/24/2023
Section Cited
CCR
87411(a)
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87411(a) Personnel Requirements
(a) Facility personnel shall at all times be sufficient in numbers, and competent to
provide the services necessary to meet resident needs…
This requirement is not met as evidenced by:
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Facility closed, change of ownership effective 10/20/2021.
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Based on interviews, the licensee did not comply with the section cited above when at times there was 1 staff only for residents requiring 2-person assist, 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: Kelly BurleyTELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Jeannette OlsonTELEPHONE: (805) 635-4718
LICENSING EVALUATOR SIGNATURE:

DATE: 08/24/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/24/2023
LIC9099 (FAS) - (06/04)
Page: 4 of 7
Control Number 29-AS-20210518134750
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 RIVERPARK
FACILITY NUMBER: 567609936
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/24/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
08/24/2023
Section Cited
CCR
87468.1(a)(1)
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87468.1(a)(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:(1) To be accorded dignity in their personal relationships with staff, residents, and other persons...This requirment was not met as
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Facility closed, change of ownership effective 10/20/2021
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evidenced by:
Based on interviews, the licensee did not comply with the section cited above when staff spoke to R3 inappropriately while changing diaper and sprayed perfume on R3’s private area, 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: Kelly BurleyTELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Jeannette OlsonTELEPHONE: (805) 635-4718
LICENSING EVALUATOR SIGNATURE:

DATE: 08/24/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/24/2023
LIC9099 (FAS) - (06/04)
Page: 5 of 7
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
05/18/2021 and conducted by Evaluator Jeannette Olson
COMPLAINT CONTROL NUMBER: 29-AS-20210518134750

FACILITY NAME:OAKMONT OF RIVERPARKFACILITY NUMBER:
567609936
ADMINISTRATOR:LIBHART, JILLFACILITY TYPE:
740
ADDRESS:901 TOWN CENTER DRIVETELEPHONE:
(805) 940-0390
CITY:OXNARDSTATE: CAZIP CODE:
93036
CAPACITY:0CENSUS: 0DATE:
08/24/2023
UNANNOUNCEDTIME BEGAN:
08:26 AM
MET WITH:TIME COMPLETED:
09:30 AM
ALLEGATION(S):
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Staff are not following the COVID-19 guidelines
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Olson delivered final findings for the above allegations via certified mail, due to the facility closed due to a change of ownership effective 10/20/2021.

On the allegation “Staff are not following the COVID-19 guidelines.” It was alleged the facility was not following COVID-19 guidelines at the time, including social distancing and isolation for positive residents. This complaint was received 5/18/2021, and the COVID-19 guidelines at the time were notated in PIN 21-17.2-ASC, released on 5/14/2021. The previous PIN, PIN 21-17.1-ASC was released on 4/23/2021. Both PINs allow for residents to participate in activities and communal dining within 6 feet of each other without wearing face masks if all residents are vaccinated. The PIN states that unvaccinated residents or groups of mixed vaccinated and unvaccinated residents should wear face masks as a precaution, however it is not a requirement.

Continued as 9099-C
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Kelly BurleyTELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Jeannette OlsonTELEPHONE: (805) 635-4718
LICENSING EVALUATOR SIGNATURE:

DATE: 08/24/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/24/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 6 of 7
Control Number 29-AS-20210518134750
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 RIVERPARK
FACILITY NUMBER: 567609936
VISIT DATE: 08/24/2023
NARRATIVE
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Information obtained through staff interviews found that most staff believed the facility was following COVID-19 protocols and guidelines. Staff interviewed stated staff wear masks and encourage residents to wear masks. Residents interviewed indicated they observed staff wear masks. Interviews revealed in the facility theater, residents sat next to each other and in the dining room there were four residents at a table not socially distanced; however, although this was not encouraged it was not disallowed per the PIN. Based on the information obtained there is insufficient evidence to support the allegation “Staff are not following the COVID-19 guidelines”. Therefore, the allegation is deemed unsubstantiated at this time.

A copy of the report was mailed.
SUPERVISOR'S NAME: Kelly BurleyTELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Jeannette OlsonTELEPHONE: (805) 635-4718
LICENSING EVALUATOR SIGNATURE:

DATE: 08/24/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/24/2023
LIC9099 (FAS) - (06/04)
Page: 7 of 7