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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 567610033
Report Date: 05/20/2022
Date Signed: 05/20/2022 04:19:53 PM


Document Has Been Signed on 05/20/2022 04:19 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 VALLEYFACILITY NUMBER:
567610033
ADMINISTRATOR:MALEKSARKISSIANS, JINAFACILITY TYPE:
740
ADDRESS:3110 ROYAL AVETELEPHONE:
(805) 416-8600
CITY:SIMI VALLEYSTATE: CAZIP CODE:
93065
CAPACITY:121CENSUS: 82DATE:
05/20/2022
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
09:56 AM
MET WITH:Vivian ReyesTIME COMPLETED:
04:35 PM
NARRATIVE
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Licensing Program Analyst (LPA) Teresa Camara conducted a Case Management - Deficiencies visit due to deficiencies found during a complaint investigation (complaint number 29-AS-20220422113450). LPA met with Health Services Director Vivian Reyes as the Executive Director Chris Andersen was in a meeting.

During LPA's visit while conducting interviews with residents on 05/20/2022, LPA observed Resident 4 (R4) did not have a bed in their room. Staff indicated it was due to R4's family stating a recliner was preferred for sleeping. LPA informed Reyes regulations require each resident have a bed in their room. Due to this being the family's choice, this is a technical violation only. However, the facility must comply with regulations and ensure R4 is equipped with a bed in their room.

LPA found a medication error involving Resident 2 (R2) on 03/10/2022 went unreported. In addition, LPA obtained records from emergency services for November 2021 and December 2021 which showed a total of 43 emergency 9-1-1 calls to the facility, 28 if which the facility did not report to CCL.

Pursuant to Title 22 CA Code of Regulations, the following deficiencies were cited (refer to LIC 809-D). Exit interview conducted. Today's reports and appeal rights were discussed. A copy of the report was emailed to the ED.
SUPERVISOR'S NAME: Jeralyn Ann PfannenstielTELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Teresa CamaraTELEPHONE: 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.

LIC809 (FAS) - (06/04)
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Document Has Been Signed on 05/20/2022 04:19 PM - It Cannot Be Edited

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

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/20/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
05/27/2022
Section Cited

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87211 Reporting Requirements
(a) Each licensee shall furnish to the licensing agency such reports as the Department may require, including, but not limited to, the following:
(1) A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days
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of the occurrence of any of the events specified in (A) through (D) below. (D) Any incident which threatens the welfare, safety or health of any resident, such as psychological abuse of a resident by staff or other residents, or unexplained absence of any resident.


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Facility records show staff gave R2 another resident's medications but did not report the error. 28 other incidents during 11/21-12/21did not get reported, which poses potential 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: Jeralyn Ann PfannenstielTELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Teresa CamaraTELEPHONE: 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
LIC809 (FAS) - (06/04)
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