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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 567610033
Report Date: 01/05/2022
Date Signed: 01/06/2022 08:48:34 AM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT
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 VALLEYFACILITY NUMBER:
567610033
ADMINISTRATOR:MALEKSARKISSIANS, JINAFACILITY TYPE:
740
ADDRESS:3110 ROYAL AVETELEPHONE:
(805) 416-8600
CITY:SIMI VALLEYSTATE: CAZIP CODE:
93065
CAPACITY:121CENSUS: DATE:
01/05/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
01:15 PM
MET WITH:Daniel OrozcoTIME COMPLETED:
03:15 PM
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Licensing Program Analyst (LPA) Teresa Camara conducted a Case Management visit to the facility regarding a self reported incident. In addition, LPA conducted a visit regarding 911 calls made by the facility which were not reported to Community Care Licensing (CCL). LPA met with Health Services Director Daniel Orozco (Orozco), LVN and LPA explained the purpose of the visit. The current interim facility Administrator/Executive Director Krystal Jenkins was not at the facility during LPA's visit. LPA arrived at the facility at 1:15 p.m. and interviewed staff at 1:20 p.m. LPA reviewed resident and employee records at 2:20 p.m.

The facility reported to CCL that on 12/17/2021 at approximately 5:20 p.m., Resident #1 (R1) was mistakenly given medications meant for Resident #2 (R2) by Staff #1 (S1). S1 immediately realized the error and reported it to other staff and management. S1 was instructed to called 911 and R1 was taken to the hospital. R1 received treatment and was discharged back to the facility at approximately 9:26 p.m the same evening. Orozco stated S1's error was due to not paying close attention during the med pass; R1 and R2 have similar first names and S1 mistakenly handed the wrong container to R1. S1 has been removed from the medication technician position pending re-training.

Orozco stated he is the individual who reports unusual incidents to CCL. He indicated he is informed by facility staff of all 911 calls and he reports those incidents to CCL. He stated the facility fax machine was having issues and it is possible the faxed reports did not go through. LPA informed Orozco he can email the incident reports to avoid these issues in the future and provided Orozco with the email address. LPA requested information regarding the 911 incidents that were not reported. Orozco said he would gather the information and forward it to LPA. Orozco was headed into two care meetings scheduled with families.

LPA will return at a later date to continue reviewing records and possibly conduct further interviews. No deficiencies cited at this time. Exit interview conducted. A copy of the report was reviewed and issued.
SUPERVISOR'S NAME: Jeralyn Ann PfannenstielTELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Teresa CamaraTELEPHONE: 818-326-4019
LICENSING EVALUATOR SIGNATURE:

DATE: 01/05/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/05/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC809 (FAS) - (06/04)
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