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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197610183
Report Date: 09/28/2022
Date Signed: 09/28/2022 04:25:12 PM

Document Has Been Signed on 09/28/2022 04:25 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., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME:OAKMONT OF VALENCIAFACILITY NUMBER:
197610183
ADMINISTRATOR:CYNTIA DRACHENBERGFACILITY TYPE:
740
ADDRESS:24070 COPPER HILL DRIVETELEPHONE:
(661) 568-6080
CITY:VALENCIASTATE: CAZIP CODE:
91354
CAPACITY: 144CENSUS: 102DATE:
09/28/2022
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
03:10 PM
MET WITH:Cyntia DrachenbergTIME COMPLETED:
04:00 PM
NARRATIVE
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Licensing Program Analyst (LPA) Angela Panushkina conducted unannounced Case management visit to the facility. LPA met with the Executive Director and explained that this visit was conducted to address the issues previously noted during complaint investigation visit conducted on 09/14/2022.

On 09/14/22 LPA obtained documents relevant to the investigation of the complaint alleging “Staff dispensed wrong medications not prescribed to resident”; (Complaint Control # 31-AS-20220805133307).

Upon review of documents LPA observed the following:

· Medication was not properly documented on Centrally Stored Medication and Destruction Records (CSMDR)

At the time a civil penalty of $23,100.00 was issued (repeated violation) and a citation was recorded on LIC809D.

Exit interview conducted. Appeal rights explained. Copy of this report signed and delivered.

SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Angela Panushkina
LICENSING EVALUATOR SIGNATURE: DATE: 09/28/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/28/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2
Document Has Been Signed on 09/28/2022 04:25 PM - It Cannot Be Edited


Created By: Angela Panushkina On 09/28/2022 at 03:09 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: OAKMONT OF VALENCIA
FACILITY NUMBER: 197610183

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/28/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/05/2022
Section Cited
CCR
87465(h)(6)A-F

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87465 Incidental Medical and Dental Care
(h) The following requirements shall apply to medications which are centrally stored: (6) The licensee shall be responsible for assuring that a record of centrally stored prescriptions...

This requirement is not met as evidenced by:
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LPA was informed that the facility completed a medication training for all staff on 09/19/22. Documents obtained and POC cleared during today's visit
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Based on record reviews and interviews, licensee did not comply with the section above, as facility staff handling medications were not properly documenting prescribed and PRN medications on CSMDR, which poses a potential health and safety rist 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:Nichelle Gillyard
LICENSING EVALUATOR NAME:Angela Panushkina
LICENSING EVALUATOR SIGNATURE:
DATE: 09/28/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/28/2022


LIC809 (FAS) - (06/04)
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