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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 565850274
Report Date: 05/22/2025
Date Signed: 05/22/2025 10:20:51 AM

Unsubstantiated


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
04/08/2025 and conducted by Evaluator Martha Arroyo
COMPLAINT CONTROL NUMBER: 29-AS-20250408080938
FACILITY NAME:PETIT OASISFACILITY NUMBER:
565850274
ADMINISTRATOR:VINCECRUZ, SUSANFACILITY TYPE:
740
ADDRESS:2802 PETIT STREETTELEPHONE:
(805) 383-8894
CITY:CAMARILLOSTATE: CAZIP CODE:
93012
CAPACITY:6CENSUS: 4DATE:
05/22/2025
UNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Susan VincecruzTIME COMPLETED:
10:45 AM
ALLEGATION(S):
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Staff do not ensure residents incontinence needs are met
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Martha Arroyo conducted a subsequent complaint visit to the above facility. The purpose of today’s visit is to deliver findings for the above allegation. The initial visit was conducted on 04/14/2025 by LPA M. Arroyo. On today’s visit, the LPA met Administrator, Susan Vincecruz and Licensee Representative, Roberto Ramirez..

On 04/14/2025, the LPA conducted a plant tour at 9:15am, conducted interviews with four staff and four residents between 10:35am and 12:40pm, conducted a medication review at 9:30am, and conducted a file review and obtained copies of pertinent documents.

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

DATE: 05/22/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/22/2025
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 7
Control Number 29-AS-20250408080938
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: PETIT OASIS
FACILITY NUMBER: 565850274
VISIT DATE: 05/22/2025
NARRATIVE
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Report Continued from LIC 9099...

It was alleged that staff do not ensure residents incontinence needs are met. It was reported that a resident may have been wearing the same diaper since discharge from the hospital. Interviews conducted with staff revealed that incontinent residents are changed at least three times per day, and all other residents are checked and changed as needed. Staff also stated that residents are alert and able to notify staff when they require assistance with changing. Furthermore, staff reported that no residents have complained about being left wet for extended periods of time. Additionally, 4 out of 4 residents interviewed expressed no concerns regarding the frequency of diaper changes or the assistance provided for their incontinence needs. Based on the information obtained and reviewed, the Department has insufficient evidence to support the allegation of “staff do not ensure residents incontinence needs are met”. Therefore, this allegation is deemed Unsubstantiated at this time.

Exit interview conducted. Report was reviewed and copy provided.

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

DATE: 05/22/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/22/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 7
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
04/08/2025 and conducted by Evaluator Martha Arroyo
COMPLAINT CONTROL NUMBER: 29-AS-20250408080938

FACILITY NAME:PETIT OASISFACILITY NUMBER:
565850274
ADMINISTRATOR:VINCECRUZ, SUSANFACILITY TYPE:
740
ADDRESS:2802 PETIT STREETTELEPHONE:
(805) 383-8894
CITY:CAMARILLOSTATE: CAZIP CODE:
93012
CAPACITY:6CENSUS: 4DATE:
05/22/2025
UNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Susan VincecruzTIME COMPLETED:
10:45 AM
ALLEGATION(S):
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9
Staff did not ensure resident had a physician’s order for bed rails
Staff are not adequately trained
Resident has missed medications
Staff do not ensure residents medication needs are being met
Staff are not meeting resident's needs
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Martha Arroyo conducted a subsequent complaint visit to the above facility. The purpose of today’s visit is to deliver findings for the above allegations. The initial visit was conducted on 04/14/2025 by LPA M. Arroyo. On today’s visit, the LPA met Administrator, Susan Vincecruz and Licensee Representative, Roberto Ramirez. Entrance interview.

During the initial visit on 04/14/2025, the LPA conducted a plant tour at 9:15am, conducted interviews with four staff and four residents between 10:35am and 12:40pm, conducted a medication review at 9:30am, and conducted a file review 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: 05/22/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/22/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 3 of 7
Control Number 29-AS-20250408080938
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: PETIT OASIS
FACILITY NUMBER: 565850274
VISIT DATE: 05/22/2025
NARRATIVE
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Report Continued from LIC 9099...

It was alleged that staff did not ensure resident had a physician’s order for bed rails. It was reported that Resident #1’s (R1’s) bed is equipped with bed rails; however, the care plan has not yet been approved by a physician. Records reviewed and interviews conducted revealed that R1 does not have a physician’s order authorizing the use of bed rails. Staff stated that the bed had been placed in the room prior to R1’s admission to the facility. Additional staff interviews further revealed that they had not reviewed R1’s file to verify if a physician’s order for bed rails was present. Furthermore, staff indicated they were currently waiting for home health to send a copy of the care plan confirming that R1 is approved to use a bed with rails. Based on record review and interviews conducted, the Department has sufficient evidence to say the alleged violation occurred. Therefore, allegation “staff did not ensure resident had a physician’s order for bed rails” is deemed Substantiated at this time.

It was also alleged that staff are not adequately trained. It was reported that facility staff is inadequate in providing care to the residents. Records reviewed revealed that facility staff have not yet completed the required 20 hours of annual training as specified by regulations. The Administrator stated that staff have completed the 20 hours and also participate in monthly refresher trainings. However, during staff interviews, employees reported having completed some training but were unsure of the total number of hours or whether it met the 20-hour requirement. Furthermore, although the facility maintained a designated training binder, the LPA was unable to verify compliance with the required training hours for the past 12 months. Based on record review and interviews conducted, the Department has sufficient evidence to say the alleged violation occurred. Therefore, allegation “staff are not adequately trained” is deemed Substantiated at this time.

It was also alleged that resident has missed medications and staff do not ensure residents medication needs are being met. It was reported that the resident is not receiving all prescribed medications, and some medications are missing and not being administered at all. Records reviewed revealed that R1 had twelve new prescriptions added to their medication list. According to inpatient discharge instructions dated 03/24/2025, R1 was prescribed several new medications, including acetaminophen–oxycodone, miconazole topical cream 2%, pantoprazole 40 mg, polyethylene glycol 3350, and selenium sulfide topical 1%.

Report Continued on LIC 9099C...

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

DATE: 05/22/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/22/2025
LIC9099 (FAS) - (06/04)
Page: 4 of 7
Control Number 29-AS-20250408080938
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: PETIT OASIS
FACILITY NUMBER: 565850274
VISIT DATE: 05/22/2025
NARRATIVE
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Report Continued from LIC 9099C...

However, these medications are not listed on R1’s Centrally Stored Medication and Destruction Record (CSMDR). Staff interviews indicated that R1 was being administered gabapentin, and staff believed that additional pain medications were unnecessary, as they considered gabapentin sufficient for pain management. However, R1 has physician orders for PRN (as-needed) medications for pain, which include acetaminophen–oxycodone (1 tablet every 4 hours as needed) and acetaminophen 650 mg (2 tablets every 8 hours as needed), both specifically prescribed for pain management. Furthermore, during the medication review on 04/14/2025, the LPA did not observe any missing medications stored centrally, as the facility did not have medications available on-site. Based on record review and interviews conducted, the Department has sufficient evidence to say the alleged violations occurred. Therefore, allegations “resident has missed medications” and “staff do not ensure residents medication needs are being met” are deemed Substantiated at this time.

It was further alleged that staff are not meeting resident's needs. It was reported that resident was recently discharged from the hospital, and facility staff had not checked R1’s blood sugar levels. A review of R1’s inpatient discharge instructions, dated 03/24/2025, revealed that R1 was to have their glucose checked twice daily for 30 days. Records reviewed and interviews conducted indicated that R1’s glucose levels had been monitored; however, when inspecting the documentation, it was found that the glucose readings were recorded from 12/14/2024 to 02/03/2025. Staff confirmed that all readings had been documented but indicated that they were unaware that R1's glucose levels needed to be checked twice daily for 30 days after being discharged from the hospital. Furthermore, although staff had been checking R1’s glucose levels daily prior to the hospitalization, they failed to continue monitoring R1’s glucose levels after discharge, as per the doctor's orders. Based on the information obtained and reviewed, the Department has sufficient evidence to say the alleged violation occurred. Therefore, allegation “staff are not meeting resident’s needs” is deemed Substantiated at this time.

The following deficiencies were observed (See LIC 809-D.) and cited from the California Code of Regulations, Title 22 and California Health and Safety Code. Failure to correct the deficiencies may result in civil penalties.

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: 05/22/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/22/2025
LIC9099 (FAS) - (06/04)
Page: 5 of 7
Control Number 29-AS-20250408080938
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: PETIT OASIS
FACILITY NUMBER: 565850274
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/22/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
05/26/2025
Section Cited
CCR
87608(a)(3)
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Postural supports may be used under the following conditions. A written order from a physician... shall be maintained in the resident’s record. The licensing agency shall be authorized to require other additional documentation if needed to verify the order. This requirement is not met as evidenced by:
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The Licensee will remove bed rails from resident's bed or obtain a physician’s order for bed rails and submit proof to CCL no later than POC due date.
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Based on record review, the Licensee did not comply with the section cited above as R1 has bed rails and an approved physician’s order is not on file, which poses an immediate health, safety, or personal rights risk to residents in care.
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Type A
05/26/2025
Section Cited
CCR
87465(a)(4)
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Incidental Medical and Dental Care (a) A plan for incidental medical and dental care shall be developed by each facility... (4) The licensee shall assist residents with self-administered medications as needed. This requirement is not met as evidenced by:
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The Licensee will review all residents’ medications and CSMDR to ensure all prescribed medications are available and submit proof to CCL no later than POC due date.
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Based on record review and interviews, the Licensee did not comply with the section cited above as facility staff are not ensuring resident is given medications as prescribed by their doctor resulting in missed dosages, which poses an immediate health, safety, or personal rights 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: 05/22/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/22/2025
LIC9099 (FAS) - (06/04)
Page: 6 of 7
Control Number 29-AS-20250408080938
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: PETIT OASIS
FACILITY NUMBER: 565850274
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/22/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
05/26/2025
Section Cited
ILS
87465(a)(2)
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A plan for incidental medical and dental care shall be developed by each facility. The plan shall encourage routine medical care and provide for assistance in obtaining such care... the licensee shall provide assistance in meeting necessary medical and dental needs. This requirement is not met as evidenced by:
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The Licensee will submit a plan on how the facility will ensure all doctor’s orders are followed and submit proof to CCL no later than POC due date.
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Based on record review and interviews, the Licensee did not comply with the section cited above as staff are not checking resident’s blood sugar levels and documenting twice a day as stated per doctor’s orders, which poses an immediate health, safety, or personal rights risk to residents in care.
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Type B
05/26/2025
Section Cited
HSC
1569.625(b)(2)
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Training requirements shall also include an additional 20 hours annually, eight hours of which shall be dementia care training, as required by subdivision (a) of Section 1569.626 and subdivision (a) of Section 1569.696. This requirement is not met as evidenced by:
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The Licensee has submitted proof that staff has completed the 20 hours training since the last visit.
POC has been met.
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Based on record review, the Licensee did not comply with the section cited above as staff has not completed the required 20 hours annual training or recorded accordingly, which poses a potential health, safety, or personal rights 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: 05/22/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/22/2025
LIC9099 (FAS) - (06/04)
Page: 7 of 7