567610033-3-23-2022-29-AS-ECAS-CCSSJM-20220323135522

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 567610033
Report Date: 03/23/2022
Date Signed: 03/23/2022 01:56:37 PM

Document Has Been Signed on 03/23/2022 01:56 PM - It Cannot Be Edited

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 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:	DATE:	03/23/2022
TYPE OF VISIT:	Case Management - Incident	UNANNOUNCED	TIME BEGAN:	01:00 PM
MET WITH:	Vivan Reyes-Health Services Director		TIME COMPLETED:	02:00 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analyst Elsie Campos arrived unannounced for a Case Management – Incident visit. The purpose of this visit is to conclude an investigation initiated during a visit conducted on 08/09/2021. The LPA met with Health Services Director Vivian Reyes and explained the reason for the visit. On 08/06/2021, the Department received a telephone call from this facility regarding a resident suicide. It was reported that on 08/05/2021, Resident #1 (R1) was found in their bedroom closet, hanging from the closet railing. The police and fire department were summoned, and R1 was pronounced dead. Community Care Licensing Division’s Investigations Branch (IB) Investigator Laura Garcia was assigned to the case. On 08/09/2021, LPA Salia Walker conducted an initial visit to gather pertinent documents. Investigator Garcia interviewed staff on 09/10/2021 at 10:00 a.m., 12/20/21 at 1:20 p.m., and on 01/31/2021 at 4:02 p.m. and 4:30 p.m.; reviewed relevant documents on 11/3/2021; interviewed collateral agency representatives on 01/10/2021 at 12:00 p.m. and on 01/10/2022; and, interviewed a family member of R1 on 01/10/2022 at 5:02 p.m. Continued on LIC 809-C

SUPERVISOR'S NAME: Jeralyn Ann Pfannenstiel	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Elsie Campos	TELEPHONE: (747) 230-3909
LICENSING EVALUATOR SIGNATURE:	DATE: 03/23/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/23/2022

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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 03/23/2022

NARRATIVE

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On the morning of 08/05/2021, it was confirmed that R1 had visited with their family from roughly 8:30 a.m. – 10:00 a.m. Thereafter, R1 and their assigned 1:1 companion sat in R1’s living room. At around 1:40 p.m., R1 mentioned to their companion that they needed to use the restroom, and it was revealed that R1 used the master bathroom, which is connected to the master bedroom. R1’s companion waited in the living room. Approximately twenty minutes went by, and R1’s companion went to check on R1. R1’s companion observed that the bathroom door was open and the lights were off. R1’s companion turned and walked out of the bathroom and noticed that R1 was suspended from their bedroom closet clothing bar. R1’s companion immediately ran out of the room and asked for help. Facility staff arrived in R1’s room, and 9-1-1 was called. Facility staff were instructed by the 9-1-1 Operator to cut R1 down from the clothing bar to place R1 on the ground. Shortly thereafter, the paramedics and fire department arrived and began performing CPR. R1 was pronounced deceased at 2:23 p.m.

The investigation revealed that R1 was admitted to this facility on 07/24/2021. A review of R1’s Physician’s Report dated 07/22/2021 documented R1’s admitting diagnosis as Depression, Hypertension, and Coronary Heart Disease. Records review revealed that R1 had been hospitalized days prior to admission due to a suicide attempt. Lastly, whereas R1 was noted as to having Depression, the report indicated that R1 was taking medication for the depression and would seek therapeutic services.

To ensure that the facility could adequately meet R1’s needs, the facility required R1 to have psychiatric clearance prior to admission, in addition to requiring a private companion to provide additional oversight due to R1’s elevated risk of self-harm and previous suicide attempts. The Physician’s Report dated 07/22/2021 noted that R1 had been discharged from the Psychiatric Department as ‘stable’, and R1’s family hired a one-to-one (1:1) companion for R1 to accompany R1 twenty-four hours a day. The private companion was not employed by this facility and was hired from an outside company. Interviews and records review revealed that R1 only needed staff assistance with the self-administration of medication. However, despite having a private companion, facility staff regularly checked in with R1 and continued to provide adequate care and supervision as required.

Continued on LIC 809-C

SUPERVISOR'S NAME: Jeralyn Ann Pfannenstiel	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Elsie Campos	TELEPHONE: (747) 230-3909
LICENSING EVALUATOR SIGNATURE:	DATE: 03/23/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/23/2022

LIC809 (FAS) - (06/04)

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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 03/23/2022

NARRATIVE

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Interviews conducted throughout the investigation revealed insufficient evidence to support the claim that the facility staff were negligent in providing adequate care and supervision to R1. It was confirmed that facility staff continued to provide care and supervision to R1, as R1’s private companion was to only accompany and assist R1. R1’s private companion was unable to provide any aspects or elements of care. Information received from R1’s companion corroborated claims that facility staff regularly checked for R1 and denied witnessing any neglect or lack of supervision on behalf of the facility staff. Staff interviews confirmed that they were in regular communication with R1’s private companion and R1’s family provided assistance and care as required. There is insufficient evidence to confirm that R1 displayed any suicidal ideations prior to the incident; the investigation revealed that on approximately 07/31/2021, R1 shared with facility staff that they had no intentions on attempting suicide.

Based on the investigation, there is insufficient evidence to support the claim that R1 committed suicide due to facility neglect and/or lack of supervision. No deficiencies cited at this time.

Exit interview conducted. A copy of the report was issued.

SUPERVISOR'S NAME: Jeralyn Ann Pfannenstiel	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Elsie Campos	TELEPHONE: (747) 230-3909
LICENSING EVALUATOR SIGNATURE:	DATE: 03/23/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/23/2022

LIC809 (FAS) - (06/04)

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