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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197610183
Report Date: 11/07/2022
Date Signed: 11/07/2022 03:47:07 PM

Document Has Been Signed on 11/07/2022 03:47 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: 104DATE:
11/07/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Sukjeevan Saund, Health Service Director. TIME COMPLETED:
04:15 PM
NARRATIVE
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Licensing Program Analyst (LPA) Angela Panushkina conducted an unannounced case management visit due to an incident that was reported to licensing. LPA met with Health Service Director and explained the reason for the visit.

LPA conducted a physical plant walk through, at approximately 11:00am, to ensure that the facility is in compliance with rules and regulations under California Code of Regulations, Title 22, Division 6.

LPA conducted interview with the Health Service Director, two (2) out of two (2) MedTechs and reviewed Resident #1 (R1's) facility records from 11:45am to 2:00pm. LPA also obtained copies of pertinent documents relevant to the investigation. Upon review of documents LPA observed the following:

  • R1's Medications were not documented on Centrally Stored Medication and Destruction Records (CSMDR)

At the time a civil penalty of $1,000.00. was issued (repeated violation) and a citation was recorded on LIC809D.

LPA also has determined further investigation is needed and will return at a later date to continue the investigation.


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: 11/07/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/07/2022
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 11/07/2022 03:47 PM - It Cannot Be Edited


Created By: Angela Panushkina On 11/07/2022 at 02:07 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: 11/07/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
11/08/2022
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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Licensee / Administrator will schedule vendorized training for all staff by 11/09/22 and submit to CCL the vendor information and scheduled date of training. Training certifications to be submitted to CCL upon completion by 11/09/22
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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 an immediate 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:Nichelle Gillyard
LICENSING EVALUATOR NAME:Angela Panushkina
LICENSING EVALUATOR SIGNATURE:
DATE: 11/07/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/07/2022


LIC809 (FAS) - (06/04)
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