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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 565850168
Report Date: 08/20/2025
Date Signed: 08/20/2025 04:52:51 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS N.ASC, 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
07/28/2025 and conducted by Evaluator Esther Cortez
COMPLAINT CONTROL NUMBER: 29-AS-20250728105832
FACILITY NAME:OAKMONT OF RIVERPARKFACILITY NUMBER:
565850168
ADMINISTRATOR:KAILEY VANDERWALLFACILITY TYPE:
740
ADDRESS:901 TOWN CENTER DRIVETELEPHONE:
(805) 940-0390
CITY:OXNARDSTATE: CAZIP CODE:
93036
CAPACITY:140CENSUS: 86DATE:
08/20/2025
UNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Kailey VanderwallTIME COMPLETED:
05:00 PM
ALLEGATION(S):
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Facility staff failed to provide hospital with POA contact information
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA), Esther Cortez conducted a subsequent complaint visit for the above allegation. Upon arrival, LPA met with Executive Director Kailey Vanderwall and explained the reason for the visit.

On 07/28/25, the LPA conducted interviews with the ED, one (1) staff, and Resident 1's (R1's) POA telephonically, conducted a file review and collected pertinent documnets relevant to the investigation. It was determined further investigation is required prior to issuing findings. During today's visit the LPA conducted a file review.

Report will continue on LIC9099-C, 2nd page.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Kasandra Lopez
LICENSING EVALUATOR NAME: Esther Cortez
LICENSING EVALUATOR SIGNATURE:

DATE: 08/20/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/20/2025
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
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS N.ASC, 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
07/28/2025 and conducted by Evaluator Esther Cortez
COMPLAINT CONTROL NUMBER: 29-AS-20250728105832

FACILITY NAME:OAKMONT OF RIVERPARKFACILITY NUMBER:
565850168
ADMINISTRATOR:KAILEY VANDERWALLFACILITY TYPE:
740
ADDRESS:901 TOWN CENTER DRIVETELEPHONE:
(805) 940-0390
CITY:OXNARDSTATE: CAZIP CODE:
93036
CAPACITY:140CENSUS: 86DATE:
08/20/2025
UNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Kailey VanderwallTIME COMPLETED:
05:00 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Facility staff failed to contact POA regarding medical emergency
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Licensing Program Analyst (LPA), Esther Cortez conducted a subsequent complaint visit for the above allegations Upon arrival, LPA met with Executive Director Kailey Vanderwall and explained the reason for the visit.

On 07/28/25, the LPA conducted interviews with the ED, one (1) staff, and Resident 1's (R1's) POA telephonically, conducted a file review and collected pertinent documnets relevant to the investigation. It was determined further investigation is required prior to issuing findings. During today's visit the LPA conducted conducted a file review. Report will continue on LIC9099-C, 2nd page.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Kasandra Lopez
LICENSING EVALUATOR NAME: Esther Cortez
LICENSING EVALUATOR SIGNATURE:

DATE: 08/20/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/20/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 29-AS-20250728105832
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME: OAKMONT OF RIVERPARK
FACILITY NUMBER: 565850168
VISIT DATE: 08/20/2025
NARRATIVE
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Regarding the allegation, "Facility staff failed to contact POA regarding medical emergency" it is the concern of the reporting party (RP) that On 7/17/2025, Resident 1 (R1) was sent to St. John's Regional Medical Center due to a rash on their face (suspected shingles), however when the facility staff sent R1 to the hospital they did not notify the POA. To investigate the allegation the LPA conducted interviews and a file review. Interview with R1's Power of Attorney (POA) revealed that they were notified of R1's hospital visit however it was after R1 was already admitted to the hospital, and that the hospital would not release any information to them due to the hospital not being provided their information. R1's POA stated they did receive three calls from facility staff about the incident and it could have been the same day R1 was taken to the hospital but after they were already admitted. Interview with Staff 1 (S1) revealed that they attempted to contact R1's POA however the Resident Information form used at the time of R1's hospital visit had the wrong POA listed. They were able to get R1's POA contact information and do not recall the exact date but recall speaking to them. In addition they stated that residents are still to be attended in emergency situations regardless if they were able to successfully contact the POA. A review of R1's Inpatient Discharge Instructions from St. John's Regional Medical Center revealed that R1 was taken to the hospital on 07/21/25 which was the date confirmed by R1's POA that they were notified of the incident. Based on interviews and records reviewed this allegation is deemed UNSUBSTANTIATED at this time.

Exit interview conducted and report provided to the Executive Director.
SUPERVISORS NAME: Kasandra Lopez
LICENSING EVALUATOR NAME: Esther Cortez
LICENSING EVALUATOR SIGNATURE:

DATE: 08/20/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/20/2025
LIC9099 (FAS) - (06/04)
Page: 5 of 5
Control Number 29-AS-20250728105832
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME: OAKMONT OF RIVERPARK
FACILITY NUMBER: 565850168
VISIT DATE: 08/20/2025
NARRATIVE
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Report was amended. Amended report emailed for signature. Signature on file.

Regarding the allegation, "Facility staff failed to provide hospital with POA contact information"; it is the concern of the Reporting Party (RP) that On 7/17/2025, Resident 1 (R1) was sent to St. John's Regional Medical Center due to a rash on their face (suspected shingles), however staff did not provide R1’s POA contact information to the hospital. To investigate the allegation the LPA conducted interviews and a file review. Interview with R1's Power of Attorney (POA) revealed that they were notified of R1's hospital visit after R1 was already admitted to the hospital, and that the hospital would not release any information to them due to the hospital not being provided their information. Additionally, the POA revealed that if they had been notified sooner of the hospital visit they would have asked for R1 to be taken to a different hospital. Interview with Staff 1 (S1) revealed that the Resident Information form used at the time of R1's hospital visit had the wrong POA listed. When the LPA showed S1 the form that was provided to the LPA as part of the emergency packet, S1 revealed that was not the same form used the day of the hospital visit. S1 indicated that they called the "POA" that was listed on the previous Resident Information form and when they answered they notified them that they would like to be taken off as R1's "true POA" and provided S1 with R1's actual POA. S1 attempted to call R1's actual POA with the information provided to the them but did not leave a voicemail with sensitive information due to not knowing if that was actually R1's POA. S1 further revealed that they recall giving the actual POA's phone number to the paramedics on a sticky note. Lastly, it was revealed that the Regional Memory Care Director updated their system with the correct POA information after the incident and a new face sheet was printed. On 07/28/25, LPA Cortez was notified by Witness 1 (W1) that in 2023, R1's POA shared their contact information and POA paperwork with the staff and W1 shared it with them as well. File review revealed that R1 has a Power of Attorney for Health Care on file with the correct POA listed on file. The LPA also observed a Resident Information form on file with a primary and second emergency contact, which were not the POA. Based on staff interview and file review, there is sufficient evidence to support the allegation and that a violation occurred; therefore, the above allegation is deemed Substantiated at this time.

The following deficiency was cited from the CA Code of Regulations, Title 22. Failure to correct the deficiencies may result in civil penalties. Exit interview held, appeal rights and report copy provided.
SUPERVISORS NAME: Kasandra Lopez
LICENSING EVALUATOR NAME: Esther Cortez
LICENSING EVALUATOR SIGNATURE:

DATE: 08/20/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/20/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 29-AS-20250728105832
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: OAKMONT OF RIVERPARK
FACILITY NUMBER: 565850168
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/20/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Request Denied
Type B
08/21/2025
Section Cited
CCR
87506(a)
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87506 Resident Records (a) The licensee shall ensure that a separate, complete, and current record is maintained for each resident in the facility or in a central administrative location readily available ...This requirement is not met as evidenced by:
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Information has been updated. Licensee agrees to submit a letter of understanding of regulation 87506 in its entirety by 08/21/25.
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Based on interviews and file review the licensee did not comply with the section cited above as R1's emergency packet was not updated with the resident correct POA information which posed a potential health and safety or personal 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.
SUPERVISORS NAME: Kasandra Lopez
LICENSING EVALUATOR NAME: Esther Cortez
LICENSING EVALUATOR SIGNATURE:

DATE: 08/20/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/20/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 5