565850168-2-9-2023-29-AS-DPEA-CPFPEY-20230227101552

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 565850168
Report Date: 02/09/2023
Date Signed: 02/09/2023 05:02:16 PM

Substantiated

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
09/06/2022 and conducted by Evaluator Zabel Chochian

COMPLAINT CONTROL NUMBER: 29-AS-20220906140504

FACILITY NAME:	OAKMONT OF RIVERPARK		FACILITY NUMBER:	565850168
ADMINISTRATOR:	ERIC MENSAH		FACILITY TYPE:	740
ADDRESS:	901 TOWN CENTER DRIVE		TELEPHONE:	(805) 940-0390
CITY:	OXNARD	STATE: CA	ZIP CODE:	93036
CAPACITY:	140	CENSUS: 92	DATE:	02/09/2023
		UNANNOUNCED	TIME BEGAN:	04:21 PM
MET WITH:	Chris Anderson		TIME COMPLETED:	05:00 PM

ALLEGATION(S):

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Facility staff failed to provide an appropriate level of supervision which resulted in Resident #1 (R1) falling and sustaining a fracture.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) conducted a subsequent complaint visit to deliver findings for the above allegation. LPA met with Chris Anderson, Executive Director and explained the reason for the visit.

On 09/06/2022, the Department received a complaint regarding an allegation of Neglect/Lack of Supervision. It was alleged that facility staff failed to provide an appropriate level of supervision which resulted in Resident #1 (R1) falling and sustaining a fractured right shoulder. The complaint was referred to the Community Care Licensing Investigations Branch (IB) and assigned to Investigator Douglas Real.

On 09/08/2022, from 1:34pm to 5:48pm, Licensing Program Analyst (LPA) Kelly Dulek conducted an initial complaint investigation for the allegation listed above. LPA Dulek arrived at the facility at 1:34pm and met with Executive Director Chris Andersen. During the visit, the LPA interviewed staff at 1:50pm, reviewed files at 2:03pm, obtained copies of pertinent documents, and toured the facility with the Executive Director at 2:38pm.

Substantiated

Estimated Days of Completion:

SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Zabel Chochian
LICENSING EVALUATOR SIGNATURE:	DATE: 02/09/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/09/2023

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 29-AS-20220906140504

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 RIVERPARK	FACILITY NUMBER: 565850168
	VISIT DATE: 02/09/2023

NARRATIVE

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On 10/14/2022, Investigator Real conducted an interview with staff, on 10/25/2022, with R1, Resident #2 (R2), and staff; and on 12/06/2022, with staff. Additionally, Investigator Real reviewed hospital medical records and the Unusual/Injury Incident report related to R1.

A summary of the Unusual/Injury Incident report dated 09/01/2022, indicated facility Staff #1 (S1) observed R1 “walking down the hallway” when R1 stumbled and fell. R1 was in pain, S1 called 911 for paramedics. Paramedics arrived and rolled R1 onto back which allowed S1 to see R1’s face was swollen, and lip was bleeding. Paramedics transported R1 to St. John’s Medical Center for evaluation. R1 returned to the facility the same day with a diagnosis of bruising to right eye and a fractured right humerus (shoulder).

A review of the St. John’s Medical records revealed on 09/01/2022, R1 was transported by ambulance and admitted to the emergency department at 1:55pm after a fall at the facility. A physical exam found mild bruising around R1’s right eye. An x-ray of R1’s right shoulder found an acute comminuted fracture of the right humeral head and neck with valgus angulation (shoulder fracture). R1’s right arm was placed in a sling and an orthopedic evaluation was ordered. R1 was discharged from the hospital back to the facility the same day.

On the allegation “Neglect/Lack of Supervision – Facility staff failed to provide an appropriate level of supervision which resulted in Resident #1 (R1) falling and sustaining a fracture” - Information obtained through interviews found that R1 was unable to provide any detail as to the fall. The staff advised that R1 is a fall risk if they walk without an assistive device. R1 uses a walker when ambulating and needs frequent reminders and prompts as R1 often forgets their walker. S1 witnessed R1 ambulating alone down a hall without their walker and fell face first. One of the staff heard the victim fall and immediately checked on the sound and observed R1 on the floor and R1’s walker was nowhere in sight. Prior to the fall, R1 had been in the activity room with the other residents and two staff supervising the residents. One of the staff in the activity room took a resident to the bathroom leaving only one staff to monitor the residents. At some point, R1 managed to leave the activity room undetected by the staff and ambulate without their walker more than twenty feet down the hall and around a corner to where they fell. (continue to LIC9099c)

SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Zabel Chochian
LICENSING EVALUATOR SIGNATURE:	DATE: 02/09/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/09/2023

LIC9099 (FAS) - (06/04)

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Control Number 29-AS-20220906140504

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 RIVERPARK	FACILITY NUMBER: 565850168
	VISIT DATE: 02/09/2023

NARRATIVE

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R1’s hospital records indicated R1 sustained a bruised right eye and a right humerus (shoulder) fracture as a result of the fall. The information and evidence obtained sufficiently supported the allegation, therefore, the allegation is deemed substantiated at this time.

A $1000 immediate civil penalty is warranted for a repeat violation of the same section and subsection cited within a year on 11/29/2022.

The Executive Director was informed that additional civil penalties might be assessed based on Health and Safety Code 1569.49(f).

Pursuant to Title 22, California Code of Regulations, the following deficiency is cited (refer to LIC 9099-D). Exit interview conducted, appeal rights discussed, and a copy of this report issued.

SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Zabel Chochian
LICENSING EVALUATOR SIGNATURE:	DATE: 02/09/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/09/2023

LIC9099 (FAS) - (06/04)

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Control Number 29-AS-20220906140504

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 RIVERPARK	FACILITY NUMBER: 565850168
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 02/09/2023

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Request Denied Type A 02/10/2023 Section Cited CCR 87464(f)(1)	1 2 3 4 5 6 7	87464(f)(1) Basic Services. (f) Basic services shall at a minimum include: (1) Care and supervision as defined in Section 87101(c)(3) and Health and Safety Code Section 1569.2(c). This requirement is not met as evidenced by:	1 2 3 4 5 6 7	Licensee will submit a plan how they will ensure appropriate resident care and supervision to residents is met. Submit to CCL by due date
	8 9 10 11 12 13 14	Based on interviews and records review, the licensee did not comply with the section cited above. Staff did not supervise R1 which resulted in R1’s fall sustaining a fracture of the right humerus and bruise of the right eye, which posed an immediate health and safety risk to residents in care.	8 9 10 11 12 13 14
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Zabel Chochian
LICENSING EVALUATOR SIGNATURE:	DATE: 02/09/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/09/2023

LIC9099 (FAS) - (06/04)

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