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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 565850168
Report Date: 04/14/2022
Date Signed: 04/14/2022 04:53:51 PM

Document Has Been Signed on 04/14/2022 04:53 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 RIVERPARKFACILITY NUMBER:
565850168
ADMINISTRATOR:BERGAN, KIMFACILITY TYPE:
740
ADDRESS:901 TOWN CENTER DRIVETELEPHONE:
(805) 940-0390
CITY:OXNARDSTATE: CAZIP CODE:
93036
CAPACITY: 140CENSUS: 88DATE:
04/14/2022
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
11:15 AM
MET WITH:Jorge MorenoTIME COMPLETED:
04:53 PM
NARRATIVE
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Licensing Program Analyst (LPA) JoAnn Rosales conducted a Case Management - Deficiencies visit at the facility. LPA met with staff Jorge Moreno Business Office Director who is authorized to review and sign reports.

During facility tour on 4/14/22 starting at 11:43 am with staff Moreno LPA observed peroxide multi surface cleaner and disinfectant, Quinidine Gluc ER 324 mg tablets belonging to staff #1 (S1), tequila, whiskey, vodka, wine, germicidal disposable wipes, glade spray and wood polish in S1's office accessible to residents as door was not locked. During facility tour on 4/14/22 at 11:52 am with staff Moreno LPA observed CPVC cement in the 2nd floor mechanical room accessible to residents as the door was left open. Interview with staff Moreno at 4:05 pm revealed that a Fire Drill was conducted with staff on 1/20/22. Staff provided documentation of a Mandatory All Staff Meeting dated 1/20/22 which includes Fire Drill and staff names. LPA did not observe documentation of drills conducted for each shift.

Pursuant to Title 22 Division 6 Chapter 8 of the CA Code of Regulations, the following deficiencies were cited (refer to LIC 809-D):

Civil Penalty issued in the amount of $250.00.

Exit interview conducted, todays reports, civil penalty and appeals rights were reviewed and emailed to the Administrator.
SUPERVISORS NAME: Kristin Heffernan
LICENSING EVALUATOR NAME: Joann Rosales
LICENSING EVALUATOR SIGNATURE: DATE: 04/14/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/14/2022
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 3
Document Has Been Signed on 04/14/2022 04:53 PM - It Cannot Be Edited


Created By: Joann Rosales On 04/14/2022 at 04:10 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. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: OAKMONT OF RIVERPARK
FACILITY NUMBER: 565850168

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/14/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
04/15/2022
Section Cited
CCR
87705(f)(1)

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87705 Care of Persons with Dementia(f)(1) The following shall be stored inaccessible to residents with dementia: Knives, matches, firearms, tools and other items that could constitute a danger to the resident(s).

This requirement is not met as evidenced by:
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Staff locked S1's office door during facility visit. Staff stated that they will provide documentation of scheduled staff training regarding regulation 87705(f)(1) to CCL by 4/15/22.
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Based on LPA's observations and record review, the licensee did not comply with the section cited above as S1's medication was observed accessible to residents which poses an immediate health risk to persons in care.
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Type A
04/15/2022
Section Cited
CCR87705(f)(2)

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87705 Care of Persons with Dementia (f)(2) The following shall be stored inaccessible to residents with dementia: Over-the-counter medication, nutritional supplements or vitamins, alcohol, cigarettes, and toxic substances such as certain plants, gardening supplies, cleaning supplies and disinfectants.
This requirement is not met as evidenced by:
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Staff locked S1's office door and mechanical room door during facility visit. Staff stated that they will provide documentation of scheduled staff training regarding regulation 87705(f)(2) to CCL by 4/15/22.
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Based on LPA's observations and record review, the licensee did not comply with the section cited above as toxic substances were observed accessible to residents which poses an immediate health risk to persons 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:Kristin Heffernan
LICENSING EVALUATOR NAME:Joann Rosales
LICENSING EVALUATOR SIGNATURE:
DATE: 04/14/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/14/2022


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 04/14/2022 04:53 PM - It Cannot Be Edited


Created By: Joann Rosales On 04/14/2022 at 04:21 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. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: OAKMONT OF RIVERPARK
FACILITY NUMBER: 565850168

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/14/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
04/25/2022
Section Cited
HSC
1569.695(c)

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1569.695 Emergency Plans (c) A facility shall conduct a drill at least quarterly for each shift. The type of emergency covered in a drill shall vary from quarter to quarter, taking into account different emergency scenarios. An actual evacuation of residents is not required during a drill. While a facility may provide an...
This requirement is not met as evidenced by:
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Staff stated that they will provide documentation of quarterly disaster plans for each shift to CCL by 4/25/22.
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Based on interview and record review, the licensee did not comply with the section cited above as quarterly disaster drills were not documented for each shift which posed a potential safety risk to persons 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:Kristin Heffernan
LICENSING EVALUATOR NAME:Joann Rosales
LICENSING EVALUATOR SIGNATURE:
DATE: 04/14/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/14/2022


LIC809 (FAS) - (06/04)
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