567610033-2-29-2024-29-AS-DPEA-D3SSAW-20240328134300

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 567610033
Report Date: 02/29/2024
Date Signed: 02/29/2024 01:56:23 PM

Substantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS N.ASC, 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
11/15/2022 and conducted by Evaluator Teresa Camara

PUBLIC

COMPLAINT CONTROL NUMBER: 29-AS-20221115091459

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:	0	CENSUS: 68	DATE:	02/29/2024
		UNANNOUNCED	TIME BEGAN:	12:07 PM
MET WITH:	Christina Spears		TIME COMPLETED:	02:15 PM

ALLEGATION(S):

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Resident sustained multiple falls due to staff's lack of supervision

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Teresa Camara conducted a subsequent complaint visit. LPA met with administrator/executive director (ED) Christina Spears and explained the reason for the visit.

During LPA's visit on 11/18/2022, LPA conducted interviews and obtained records. During LPA's visit on 2/12/2024 LPA conducted interviews with staff at 1:07 p.m., 3:07 p.m., and 3:20 p.m., and reviewed documents starting at 1:07 p.m.

On 2/29/2024, LPA conducted a subsequent visit to deliver an amended report as findings on one of the allegations in the original report was incorrect.

(continued on 9099-C)

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Desaree Perera	TELEPHONE: (818) 593-4347
LICENSING EVALUATOR NAME: Teresa Camara	TELEPHONE: 818-326-4019
LICENSING EVALUATOR SIGNATURE:	DATE: 02/29/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/29/2024

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

LIC9099 (FAS) - (06/04)

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Control Number 29-AS-20221115091459

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: OAKMONT OF SIMI VALLEY	FACILITY NUMBER: 567610033
	VISIT DATE: 02/29/2024

NARRATIVE

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(continued from 9099)

Regarding the allegation Resident 1 (R1) was falling due to lack of supervision:

R1 lived at the facility for a total of approximately 20 days. According to the facility’s “Resident Care Notes”, R1 was observed to have fallen at least six times:
9/27/2022 at 3:30 a.m. (suffered skin tear on left leg)
9/27/2022 at 5:00 p.m. (suffered skin tear on right arm)
9/27/2022 at NOC (time not noted) (assisted fall, caregiver present, no injury observed)
9/16/2022 at 5:35 p.m. (found in another resident’s room on the floor, no injury observed)
9/15/2022 at 2:23 p.m. (no injury observed)
9/11/2022 at 1:43 p.m. (assisted fall, caregiver present, no injury observed)

According to information in staff interviews, R1 would frequently slide out of their wheelchair, chair or bed. Sometimes R1 was observed standing up without assistance and then fall. Injuries were limited to skin tears and bruising; there was never an indication R1 hit their head. All the falls were reported to R1’s representative as well as their hospice agency. Due to R1's need for increased supervision, the Health Services Director (HSD) conducted a re-assessment on 9/21/2022 after R1 was living there for approximately ten days. At that time, the HSD recommended to R1's representative that R1 should have a one to one (1:1) caregiver but this option was cost prohibitive for R1. The Memory Care Director (MCD) stated status checks are typically conducted every one to two hours. They increased status checks on R1 to every 30-60 minutes in lieu of R1’s representative hiring a 1:1 caregiver. The MCD stated R1 did not like to participate in group activities or be in groups. During meals the MCD would have R1 seated at a table outside the MCD's office in order to keep an eye on R1. R1 had a tendency to want to do things for themselves and get up out of their wheelchair. The MCD would remind R1 to have a seat and someone would bring them whatever they wanted. Sometimes the MCD would have R1 sit in the MCD's office to occupy R1 for a while and get R1 out of their room. R1 preferred to stay in their room and would frequently get up without calling for assistance.

SUPERVISOR'S NAME: Desaree Perera	TELEPHONE: (818) 593-4347
LICENSING EVALUATOR NAME: Teresa Camara	TELEPHONE: 818-326-4019
LICENSING EVALUATOR SIGNATURE:	DATE: 02/29/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/29/2024

LIC9099 (FAS) - (06/04)

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Control Number 29-AS-20221115091459

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: OAKMONT OF SIMI VALLEY	FACILITY NUMBER: 567610033
	VISIT DATE: 02/29/2024

NARRATIVE

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(continued from 9099-C)

Based on interviews and records reviewed, R1 required more supervision than what was agreed upon in R1’s updated Service Plan dated 9/21/2022. The HSD stated she had recommended a 1:1 caregiver for R1 but R1’s representative stated they could not afford the additional cost. At that point, the facility should have provided the additional supervision until R1’s representative could find more appropriate placement for R1 and the facility should have issued a 30 day eviction notice to R1 as they could no longer meet the resident’s needs without R1’s representative paying for 1:1 care. Therefore, this allegation R1 sustained multiple falls due to staff's lack of supervision is Substantiated.

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 issued.

SUPERVISOR'S NAME: Desaree Perera	TELEPHONE: (818) 593-4347
LICENSING EVALUATOR NAME: Teresa Camara	TELEPHONE: 818-326-4019
LICENSING EVALUATOR SIGNATURE:	DATE: 02/29/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/29/2024

LIC9099 (FAS) - (06/04)

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Control Number 29-AS-20221115091459

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: OAKMONT OF SIMI VALLEY	FACILITY NUMBER: 567610033
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 02/29/2024

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 03/07/2024 Section Cited CCR 87464(d)	1 2 3 4 5 6 7	87464 Basic Services (d) A facility need not accept a particular resident for care. However, if a facility chooses to accept a particular resident for care, the facility shall be responsible for meeting the resident's needs as identified in the pre-admission appraisal specified in Section 87457,	1 2 3 4 5 6 7	The ED agreed to review this topic with her staff and management team and provide documentation of this training to CCL on or before 3/7/2024.
	8 9 10 11 12 13 14	Pre-admission Appraisal and providing the other basic services specified below, either directly or through outside resources. Based on interviews and records review, the licensee did not comply with the section cited above.	8 9 10 11 12 13 14	According to the HSD, R1 needed 1:1 supervision which R1 could not afford. The facility chose to retain R1 in the community but did not provide 1:1 care which resulted in additional falls and posed an immediate health and safety risk to residents in care.
	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: Desaree Perera	TELEPHONE: (818) 593-4347
LICENSING EVALUATOR NAME: Teresa Camara	TELEPHONE: 818-326-4019
LICENSING EVALUATOR SIGNATURE:	DATE: 02/29/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/29/2024

LIC9099 (FAS) - (06/04)

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