567610033-5-20-2022-29-AS-JAPL-CQF264-20230330170628

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 567610033
Report Date: 05/20/2022
Date Signed: 05/20/2022 04:22:12 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
04/22/2022 and conducted by Evaluator Teresa Camara

PUBLIC

COMPLAINT CONTROL NUMBER: 29-AS-20220422113450

FACILITY NAME:	OAKMONT OF SIMI VALLEY		FACILITY NUMBER:	567610033
ADMINISTRATOR:	MALEKSARKISSIANS, JINA		FACILITY TYPE:	740
ADDRESS:	3110 ROYAL AVE		TELEPHONE:	(805) 416-8600
CITY:	SIMI VALLEY	STATE: CA	ZIP CODE:	93065
CAPACITY:	121	CENSUS: 82	DATE:	05/20/2022
		UNANNOUNCED	TIME BEGAN:	09:56 AM
MET WITH:	Chris Andersen and Vivian Reyes		TIME COMPLETED:	04:35 PM

ALLEGATION(S):

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Staff are mismanaging resident's medication

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Teresa Camara conducted a subsequent complaint investigation visit regarding the above noted allegations. LPA met with Executive Director (ED) Chris Andersen and Health Services Director Vivian Reyes and explained the reason for the visit.

During LPA's visit LPA reviewed records starting at 10:00 a.m., met with ED at 10:19 a.m., interviewed staff 1 (S1) at 10:52 a.m., staff 2 (S2) at 11:07 a.m., staff 3 (S3) at 1:29 p.m., and Resident 4 (R4) at 12:15 p.m.

Based on facility records reviewed there were three medication errors in which residents were given another resident's medications; Resident 1 (R1) occurred on 12/17/2021, Resident 2 (R2) occurred on 03/10/2022, and Resident 3 (R3) occurred on 04/15/2022. The incidents with R1 and R3 were reported to CCL, however the incident with R2 was not reported. The above noted allegtion 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. Today's reports and appeal rights were discussed. A copy of the report was emailed to the ED.

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Jeralyn Ann Pfannenstiel	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Teresa Camara	TELEPHONE: 818-326-4019
LICENSING EVALUATOR SIGNATURE:	DATE: 05/20/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/20/2022

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

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
04/22/2022 and conducted by Evaluator Teresa Camara

PUBLIC

COMPLAINT CONTROL NUMBER: 29-AS-20220422113450

FACILITY NAME:	OAKMONT OF SIMI VALLEY		FACILITY NUMBER:	567610033
ADMINISTRATOR:	MALEKSARKISSIANS, JINA		FACILITY TYPE:	740
ADDRESS:	3110 ROYAL AVE		TELEPHONE:	(805) 416-8600
CITY:	SIMI VALLEY	STATE: CA	ZIP CODE:	93065
CAPACITY:	121	CENSUS: 82	DATE:	05/20/2022
		UNANNOUNCED	TIME BEGAN:	09:56 AM
MET WITH:	Chris Andersen and Vivian Reyes		TIME COMPLETED:	04:35 PM

ALLEGATION(S):

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Staff left resident in soiled diaper for extended period of time

INVESTIGATION FINDINGS:

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Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Jeralyn Ann Pfannenstiel	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Teresa Camara	TELEPHONE: 818-326-4019
LICENSING EVALUATOR SIGNATURE:	DATE: 05/20/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/20/2022

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

Page: 2 of 4

Control Number 29-AS-20220422113450

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 SIMI VALLEY	FACILITY NUMBER: 567610033
	VISIT DATE: 05/20/2022

NARRATIVE

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(continued from 9099-A)

The ED conducted a test with pull-up briefs used by R1 to see how long it took for the materials within the brief to congeal once it was exposed to liquids; the material congeals within approximately 5 minutes presumably to keep the material next to the skin as dry as possible. Therefore, it is not possible to know how long R1's diaper was soiled based on the diaper condition of congealed material.

LPA reviewed the facility's incontinence care records for R1. R1 is checked every two hours. In addition, facility staff encourage R1 to use the toilet. R1 resists incontinence care so facility staff make efforts to engage R1 in distractions in order to gain R1's cooperation.

Based on LPA's observations, interviews and record review, the above noted allegation is deemed Unsubstantiated at this time. A copy of the report was issued to ED.

SUPERVISOR'S NAME: Jeralyn Ann Pfannenstiel	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Teresa Camara	TELEPHONE: 818-326-4019
LICENSING EVALUATOR SIGNATURE:	DATE: 05/20/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/20/2022

LIC9099 (FAS) - (06/04)

Page: 3 of 4

Control Number 29-AS-20220422113450

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 SIMI VALLEY	FACILITY NUMBER: 567610033
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 05/20/2022

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 05/23/2022 Section Cited CCR 87465(a)(4)	1 2 3 4 5 6 7	87465 Incidental Medical and Dental Care (a) A plan for incidental medical and dental care shall be developed by each facility. The plan shall encourage routine medical and dental care and provide for assistance in obtaining such care, by compliance with the following:	1 2 3 4 5 6 7	The Health Services Director already conducted medication training with staff. She will provide CCL with evidence of the training to CCL on or before 5/23/2022.
	8 9 10 11 12 13 14	(4) The licensee shall assist residents with self-administered medications as needed. Facility records show staff gave R1, R2 and R3 other residents' medications, which poses an immediate health and safety risk to residents in care.	8 9 10 11 12 13 14
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

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: Jeralyn Ann Pfannenstiel	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Teresa Camara	TELEPHONE: 818-326-4019
LICENSING EVALUATOR SIGNATURE:	DATE: 05/20/2022

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/20/2022

LIC9099 (FAS) - (06/04)

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