567610033-9-16-2022-29-AS-JAPL-CJEPW6-20220919114013

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 567610033
Report Date: 06/29/2022
Date Signed: 09/16/2022 03:12:11 PM

Unsubstantiated

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
10/18/2021 and conducted by Evaluator Teresa Camara

PUBLIC

COMPLAINT CONTROL NUMBER: 29-AS-20211018111041

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: 76	DATE:	06/29/2022
		UNANNOUNCED	TIME BEGAN:	09:50 AM
MET WITH:	Chris Andersen and Vivian Reyes		TIME COMPLETED:	11:20 AM

ALLEGATION(S):

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Neglect/Lack of Supervision – Facility staff failed to provide an appropriate level of supervision which resulted in Resident #1 (R1) sustaining a stage III pressure injury.
Staff is not showering the resident.
Staff is not dressing the resident.
Staff is not properly assisting resident with the self-administration of medication.
Staff are not properly safeguarding resident’s medical supplies.
Staff did not propely safeguard the resident's scooter.
Medical records were not accurate.

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 Vivan Reyes explained the reason for the visit.

On 10/18/2021, the Department received a complaint alleging the facility staff failed to provide an appropriate level of supervision which resulted in Resident #1 (R1) sustaining a stage III pressure injury on R1’s left arm. The complaint was referred to Community Care Licensing Investigations Branch (IB) and assigned to Investigator Douglas Real.

(continued on 9099-C "page 2")

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: 06/29/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/29/2022

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 5

Control Number 29-AS-20211018111041

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: 06/29/2022

NARRATIVE

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(page 2)

On 10/19/2021, from 1:18 p.m. to 4:35 p.m., Licensing Program Analyst (LPA) Teresa Camara conducted the initial complaint investigation visit. LPA Camara met with Executive Director/Administrator Jina Maleksarkissians and explained the reason for the visit. During the visit, the LPA conducted a brief physical plant tour at 2:10 p.m., interviewed the Administrator at 1:43 p.m., interviewed Staff #1 (S1) at 2:20 p.m., interviewed Staff #2 (S2) at 3:00 p.m. and reviewed records at 2:40 p.m. The LPA determined further investigation was required prior to issuing findings and requested copies of pertinent documents relevant to the investigation.

Investigator Real conducted an interview with R1’s representative on 10/31/2021; with R1 on 11/04/2021; with facility staff on 12/14/2021; with R1’s primary care physician’s office on 01/12/2022; with facility residents and staff on 01/26/2022; and with the home health services on 01/28/2022. Additionally, the investigator reviewed records related to R1 including the physician’s report, facility care notes, and the home health records.

Information obtained from R1’s physician report, dated 07/23/2021, listed R1’s primary diagnosis as Alzheimer’s dementia. R1 was listed as being able to communicate needs, with no motor impairment or paralysis noted. Facility care notes dated from 09/13/2021 indicate R1 was found to have a skin tear on their left elbow. When asked, R1 reported to staff that they scraped their arm on the wall when riding their scooter in the facility; other times, R1 was unsure how the injury occurred. It was cleaned and covered and R1’s representative was notified. Notes from 09/14/2021 indicate the wound was cleaned, covered and R1’s representative requested the wound be cleaned three times a day. On 09/28/2021, the notes indicate the wound was not getting better and it was discussed with R1’s representative. R1’s representative scheduled a physician’s appointment to assess the wound. R1 was seen by the home health nurse on 10/06/2021. The home health notes indicate R1 was treated from 10/06/2021 to 11/05/2021.

(continued on 9099-C "page 3")

SUPERVISOR'S NAME: Jeralyn Ann Pfannenstiel	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Teresa Camara	TELEPHONE: 818-326-4019
LICENSING EVALUATOR SIGNATURE:	DATE: 06/29/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/29/2022

LIC9099 (FAS) - (06/04)

Page: 4 of 5

Control Number 29-AS-20211018111041

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: 06/29/2022

NARRATIVE

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(page 3)

Information obtained through the course of the investigation found that R1 did not report any complaints or problems regarding the facility. R1 was able to ambulate with a walker or on R1’s scooter. R1’s representative was unhappy with the care R1 received and claimed they discovered the wound on R1’s arm on 09/15/2021 and no one from the facility told them of the wound prior to the discovery. The facility employees denied the allegations and reported that R1’s representative was notified of the skin tear. Facility records indicate R1’s representative was notified of the wound on 09/13/2021. R1’s representative stated they took R1 to the doctor where the wound was diagnosed as a stage III pressure injury. Investigator Real contacted R1’s primary care physician’s office and was informed that R1 was seen by the nurse practitioner who did not stage the injury on R1’s arm. R1’s home health records indicated R1 was diagnosed with a stage II pressure injury. Investigator Real contacted the home health agency and was informed that R1’s wound was in fact diagnosed as a stage II and not a stage III pressure injury.

Based on the information obtained, the Department does not have sufficient evidence to support the allegation that ‘facility staff failed to provide an appropriate level of supervision which resulted in Resident #1 (R1) sustaining a stage III pressure injury’. Therefore, the allegation is deemed Unsubstantiated at this time.

Regarding the allegation ‘staff is not showering the resident’, during LPA’s interviews with staff it was found R1 frequently refused showers. Staff were working with R1 to offer showers at different times of the day, different staff members offered to shower R1 and sponge baths were given when R1 refused showers. In addition, management was attempting to work with R1’s representative to develop a plan and possibly offer an upgraded spa-like experience to R1, however R1 was moved out of the facility prior to coming to an agreement with R1's representative on an alternative approach. Based on the information gathered, the facility staff and management made every effort to ensure R1 was appropriately bathed as scheduled, therefore this allegation is deemed Unsubstantiated at this time.

(continued on 9099-C "page 4")

SUPERVISOR'S NAME: Jeralyn Ann Pfannenstiel	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Teresa Camara	TELEPHONE: 818-326-4019
LICENSING EVALUATOR SIGNATURE:	DATE: 06/29/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/29/2022

LIC9099 (FAS) - (06/04)

Page: 2 of 5

Control Number 29-AS-20211018111041

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: 06/29/2022

NARRATIVE

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(page 4)

Regarding the allegation ‘staff is not dressing the resident’, during LPA’s interviews with staff it was found R1’s representative was concerned R1 was dressing in mismatched layers of clothing. Staff indicated they assisted R1 with dressing in the morning, however R1 would change clothing or add additional layers of clothing throughout the day. When staff would attempt to encourage R1 to change but R1 would resist. Staff allowed R1 to dress as R1 wished in an effort to ensure R1’s personal rights were not violated, therefore this allegation is deemed Unsubstantiated at this time.

Regarding the allegation ‘staff is not properly assisting resident with the self-administration of medication’, LPA reviewed R1’s medication administration records and physician’s orders and found no evidence of medication errors for R1, therefore this allegation is deemed Unsubstantiated at this time.

Regarding the allegation ‘staff are not properly safeguarding resident’s medical supplies’, during LPA’s interviews with staff it was found R1’s medical supplies for R1’s pressure injury care were taken from R1’s room and stored in the medication room as is done for all residents to ensure safe storage, therefore this allegation is deemed Unsubstantiated at this time.

Regarding the allegation ‘staff did not properly safeguard the resident's scooter’, during LPA’s interviews with staff it was found R1’s scooter was parked and charged in R1’s room. R1 sometimes had difficulty navigating the scooter and would occasionally forget the scooter was still plugged in when taking off. This allegation was specifically regarding R1’s scooter charging cord being broken. Nobody witnessed how the charging cord was broken. It was assumed R1 may have taken off before ensuring the scooter was unplugged as R1 had done in the past. Regardless of fault, the executive director purchases a new charging cord for R1. LPA interviewed resident #4 (R4) who required assistance with their scooter and R4 indicated no issues with staff assistance. R4 stated staff ensure their scooter is charged every evening and staff have never caused damage to any of R4's property. Therefore, this allegation is deemed Unsubstantiated at this time.

(continued on 9099-C "page 5")

SUPERVISOR'S NAME: Jeralyn Ann Pfannenstiel	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Teresa Camara	TELEPHONE: 818-326-4019
LICENSING EVALUATOR SIGNATURE:	DATE: 06/29/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/29/2022

LIC9099 (FAS) - (06/04)

Page: 5 of 5

Control Number 29-AS-20211018111041

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: 06/29/2022

NARRATIVE

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(page 5)

Regarding the allegation ‘medical records were not accurate’, during LPA’s interviews with staff and review of records, there was no evidence the medical records at the facility were tampered with or inaccurate. Facility medication technicians send requests with residents' list of medications to residents' physicians to ensure they have an accurate up-to-date list of medications a resident should be taking. These lists include regularly scheduled medications, over the counter medications and prn medications. The lists give residents' physicians the opportunity to discontinue, change or add medications as needed. Therefore, this allegation is deemed Unsubstantiated at this time.

Exit interview conducted and a copy of the report was emailed to the executive director and health services director.

SUPERVISOR'S NAME: Jeralyn Ann Pfannenstiel	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Teresa Camara	TELEPHONE: 818-326-4019
LICENSING EVALUATOR SIGNATURE:	DATE: 06/29/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/29/2022

LIC9099 (FAS) - (06/04)

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