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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 565850169
Report Date: 02/19/2025
Date Signed: 02/19/2025 11:16:14 AM

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
10/07/2024 and conducted by Evaluator Martha Arroyo
COMPLAINT CONTROL NUMBER: 29-AS-20241007173434
FACILITY NAME:OAKMONT OF CAMARILLOFACILITY NUMBER:
565850169
ADMINISTRATOR:FOERSCHNER, BRADLEEFACILITY TYPE:
740
ADDRESS:305 DAVENPORT STREETTELEPHONE:
(805) 738-3600
CITY:CAMARILLOSTATE: CAZIP CODE:
93012
CAPACITY:150CENSUS: 81DATE:
02/19/2025
UNANNOUNCEDTIME BEGAN:
09:10 AM
MET WITH:Jenay Turgeon - Buisiness Office DirectorTIME COMPLETED:
11:30 AM
ALLEGATION(S):
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Staff mismanaged resident medication.
Staff are not following reporting requirements.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA), Martha Arroyo conducted a subsequent complaint visit to the above facility. The purpose of the visit is to deliver findings for the above allegations. The initial visit was conducted on 10/11/2024 by LPAs M. Arroyo and B. Balisi and a subsequent visit was conducted on 01/21/2025 by LPA M. Arroyo. On today's visit, LPA Arroyo met with Business Office Director, Jenay Turgeon. Entrance interview.

During the initial visit on 10/11/2024, LPAs Arroyo and Balisi conducted a medication review at 12:25pm and obtained copies of pertinent documents relevant to the investigation. On 01/21/2025, LPA Arroyo conducted a medication review at approximately 10:35am, conducted interviews with four staff between 10:50am and 1:00pm, and obtained copies of pertinent documents.

Report Continued on LIC 9099C...
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Martha Arroyo
LICENSING EVALUATOR SIGNATURE:

DATE: 02/19/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/19/2025
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 3
Control Number 29-AS-20241007173434
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 CAMARILLO
FACILITY NUMBER: 565850169
VISIT DATE: 02/19/2025
NARRATIVE
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Report Continued from LIC 9099...

It was alleged that staff mismanaged resident medication. It was reported that medication errors have occurred with routine medications and wrong dosages were being administered. Record review of Resident #1's (R1) medication records and interviews conducted revealed a discrepancy between the prescribed dosage of Temazepam and the actual dosage administered over several days. Initially, R1 had been prescribed a 30mg dosage of Temazepam (1 capsule) to be taken at bedtime. On 09/19/2024, R1’s physician issued a prescription change, reducing the daily dosage to 15mg (1 capsule), with the new dosage intended to take effect on 09/20/2024. However, despite this directive, the medication administration did not reflect the updated prescription. The Centrally Stored Medication and Destruction Record (CSMDR) indicated that the 30mg dosage continued to be administered until 09/21/2024. Furthermore, the change to the 15mg dosage did not occur until 09/22/2024, a full two days after the physician's order. Based on the information obtained during the course of the investigation, the Department has sufficient evidence to support the allegation of “staff mismanaged resident medication”. Therefore, this allegation is deemed SUBSTANTIATED at this time.

It was also alleged that staff are not following reporting requirements. It was reported that medication errors were occurring but were not being reported. Record review and interviews conducted revealed that there was no incident report (LIC 624) on file and the department was not contacted in a timely manner in regard to the facility having medication errors and/or administering wrong medication dosage to residents in care. This medication error which was revealed to be wrong dosage administered to the resident through a medication review was not reported or communicated with the Department. Based on the information obtained and reviewed, the Department has sufficient evidence to support the allegation of “staff are not following reporting requirements”. Therefore, this allegation is deemed SUBSTANTIATED at this time.

Exit interview conducted. A copy of the report and appeal rights were provided.

SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Martha Arroyo
LICENSING EVALUATOR SIGNATURE:

DATE: 02/19/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/19/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 29-AS-20241007173434
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 CAMARILLO
FACILITY NUMBER: 565850169
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/19/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
02/28/2025
Section Cited
CCR
87465(c)(2)
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87465(c)(2) Incidental and Medical Care: .... Once ordered by the physician the medication is given according to the physician's directions.

This requirement has not been met as evidenced by:
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Licensee agrees to schedule medication training for all med-techs that includes documentation and medication distribution by a 3rd party vendor and submit proof to CCL by COB 02/28/2025.
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Based on record review, the licensee did not comply with the section cited above as R1 was given the wrong dosage of medication after a new order was sent by their doctor, which poses an immediate health and safety risk to residents in care.
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Type B
02/28/2025
Section Cited
CCR
87211(a)(1)(D)
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87211(a)(1)(D) Each licensee shall furnish to the licensing agency such reports as the Department may require, including: Any incident which threatens the welfare, safety or health of any resident… This requirement has not been met as evidenced by:
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Licensee agrees to review section cited and provide a statement of understanding and submit to CCL by COB 02/28/2025.
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Based on record review and interviews, the licensee did not comply with the section cited above as Licensee did not submit an incident report to the Department within seven (7) days of occurrence on medication errors, which poses a potential 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.
SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Martha Arroyo
LICENSING EVALUATOR SIGNATURE:

DATE: 02/19/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/19/2025
LIC9099 (FAS) - (06/04)
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