Inspection Reports for Oakmont of Valencia

The visit was an annual audit inspection conducted as a subsequent annual continuation visit to review resident records and medication management.

The inspection revealed discrepancies in medication administration records for 6 residents, including off-count errors and leftover medications from prior cycles that were not properly disposed of or returned, indicating improper medication management and potential health and safety risks.

The inspection was an annual continuation case management visit conducted to audit staff and resident records and to assess compliance with licensing requirements.

The Licensing Program Analyst reviewed 10 resident files and 10 staff files, finding that resident records had current physician reports and service plans, and staff records had up-to-date training, valid first aid/CPR certificates, and criminal record clearances. The annual inspection was not completed as medication records and resident medication audits were pending.

Licensing Program Analyst Tuesday Cabiness conducted an Annual Required visit and inspection of the facility to evaluate compliance with licensing requirements.

The inspection included a review of resident files, physical plant inspection of residents' rooms, common areas, and kitchen. Due to time constraints, the annual inspection was not completed and will be continued at a later date.

The visit was an unannounced complaint investigation triggered by allegations received on 2024-02-21 regarding staffing shortages affecting resident care at Oakmont of Valencia.

The investigation found two allegations unsubstantiated: residents not being changed timely and residents not receiving timely assistance due to staffing shortages. One allegation was substantiated: staff failed to administer a prescribed inhaler dose to Resident #1, posing an immediate health and safety risk.

The complaint included allegations that residents were not changed timely and not receiving assistance timely due to lack of staff, and that medications were not given as prescribed. The first two allegations were unsubstantiated based on interviews, observations, and record reviews. The medication administration allegation was substantiated based on a missed inhaler dose confirmed by the facility's internal investigation and Special Incident Report.

The visit was a case management follow-up to review two Special Incident Reports submitted by the facility involving a medication administration error and an un-witnessed altercation between two residents.

The inspection found that Resident #1 received medication daily instead of three times per week as prescribed, constituting a medication error with no adverse reactions but requiring hospital evaluation. Additionally, an un-witnessed altercation between two residents resulted in minor injuries and police involvement. A citation and civil penalty were issued for repeated violations.

The inspection visit was a case management annual continuation to continue the annual inspection of the facility.

During the visit, the Licensing Program Analyst reviewed 11 client files and 11 staff records. Medication review and continuation of resident records will be completed at a later date. An exit interview and copy of the report were provided.

A case management visit was conducted regarding a Special Incident Report (SIR) about eight residents who were not administered their prescribed medication on 03/17/2025.

The facility failed to administer medication to eight residents as prescribed, posing an immediate health and safety risk. The facility was previously on a non-compliance plan and has had multiple complaints and case management visits related to medication errors and reporting failures.

The visit was complaint-related due to a Special Incident Report involving eight residents not receiving their prescribed medication. The facility had prior complaints and case management visits related to medication errors and reporting failures. The complaint was substantiated as deficiencies were found.

The visit was an unannounced complaint investigation triggered by an allegation that staff did not notice a resident's change in condition, resulting in a urinary tract infection (UTI) that staff failed to detect.

The investigation found that Resident 1 (R1) was admitted and developed multiple UTIs, with appropriate treatment and communication with the family and primary care physician. The allegation that staff failed to notice R1's UTI was determined to be unsubstantiated based on documentation and interviews.

The complaint alleged that staff did not notice a resident's change in condition, leading to an undetected UTI. The allegation was found to be unsubstantiated after review of documentation and interviews.

The visit was an unannounced complaint investigation triggered by allegations received on 07/13/2023 regarding medication dispensing, resident positioning resulting in a fall, and infection control policy maintenance.

The investigation found insufficient evidence to substantiate any of the allegations. Medication was administered according to doctor's orders once received, the resident's fall was documented with no injuries and no evidence of improper positioning, and infection control policies were maintained with no recent infection exposures reported.

The complaint involved three allegations: 1) staff did not ensure medication was dispensed as prescribed, 2) staff did not ensure proper resident positioning resulting in a fall, and 3) staff did not maintain infection control policies. All allegations were found unsubstantiated based on interviews, document reviews, and incident reports.

The visit was an unannounced complaint investigation conducted in response to allegations received on 2023-07-13 regarding feeding assistance, food quality, and bathing assistance at the facility.

Based on interviews, observations, and record reviews, there was insufficient evidence to substantiate the allegations. Staff were observed providing feeding assistance as needed, food quality was found to be good with resident input, and bathing assistance was provided timely with support from private caregivers.

The complaint investigation addressed three allegations: 1) staff not providing feeding assistance, 2) staff not serving food of good quality, and 3) staff not providing bathing assistance in a timely manner. All allegations were determined to be unsubstantiated based on evidence collected during the investigation.

The visit was an unannounced complaint investigation conducted in response to a complaint received on 2023-03-21 regarding multiple allegations including resident falls, failure to seek timely medical attention, unattended residents, failure to meet reporting requirements, and failure to protect residents from harm.

The investigation found insufficient evidence to substantiate any of the allegations. The resident falls were deemed unavoidable due to medical conditions, medical attention was appropriately sought, residents were not left unattended for extended periods, incident reports were submitted timely, and there was no evidence of harm caused by another resident.

The complaint involved five allegations: 1) Resident sustained a fall and injuries while in care; 2) Staff failed to seek medical attention timely; 3) Staff left resident unattended for extended periods; 4) Staff failed to meet reporting requirements; 5) Staff failed to protect resident from harm by another resident. All allegations were found unsubstantiated based on interviews, record reviews, and observations.

Licensing Program Analyst Tuesday Cabiness conducted an Annual Required visit and inspection of the facility to evaluate compliance with licensing requirements.

The facility was toured and observed to be generally sanitary and properly furnished, with adequate food supplies and safety equipment. Due to time constraints, the annual inspection was not completed and will be resumed later to audit resident, staff, and medication records.

The visit was a case management inspection triggered by a Special Incident Report (SIR) regarding a medication error where staff administered the wrong medication to resident #1.

The facility reported the medication error incident and implemented additional medication training. The resident was sent to the hospital for evaluation and returned with no adverse effects documented. A citation was issued and a follow-up visit is planned.

The complaint was substantiated as staff administered the wrong medication to resident #1. The facility reported the incident via SIR and took corrective action including additional training. Further review and follow-up are planned.

This was an unannounced complaint investigation visit triggered by multiple allegations received on 05/06/2022 concerning resident hygiene, room odor, laundry service, soiled diapers, food service, safeguarding personal belongings, and dehydration.

The investigation substantiated allegations that staff failed to meet resident hygiene needs, including failure to clean shoes saturated with diarrhea, malodorous resident rooms due to clogged toilets, and inadequate laundry service related to soap issues. Other allegations regarding soiled diapers, food service, safeguarding personal belongings, and dehydration were unsubstantiated based on interviews, observations, and record reviews.

The complaint investigation was substantiated for allegations related to hygiene needs, malodorous rooms, and laundry service. Other allegations including soiled diapers, inadequate food service, safeguarding personal belongings, and severe dehydration were unsubstantiated.

The inspection was conducted as a Case Management visit in conjunction with a complaint investigation regarding multiple falls sustained by resident #1 (R1) at the facility.

The facility failed to report all falls of resident #1 accurately, submitting only one Special Incident Report (SIR) when multiple falls occurred. This failure to report is considered a potential health and safety risk to residents in care. A citation was issued and the Plan of Correction was cleared.

Complaint control #31-AS-20240618151354 regarding multiple falls of resident #1. The complaint was substantiated as the facility failed to report all falls.

Unannounced complaint investigation visit conducted due to allegations received on 01/11/2024 regarding hot water availability, residents' incontinence and bathing needs, and elevator functionality at Oakmont of Valencia facility.

The investigation found that although there were plumbing issues causing low water temperature in some resident rooms and an elevator malfunction, the facility took appropriate corrective actions including notifying families, using vacant rooms for hot water needs, and contacting repair services. All allegations were deemed unsubstantiated based on documentation and interviews.

The complaint included four allegations: 1) lack of hot water for residents, 2) unmet incontinence needs, 3) unmet bathing needs, and 4) elevator not in working condition. All allegations were investigated and found unsubstantiated after review of documents, interviews, and observation of corrective actions.

A Case Management visit was conducted to amend previous reports related to a complaint and a case management incident dated 06/15/2023.

The visit involved reviewing and amending prior reports; an exit interview was conducted and a copy of the report was signed and delivered.

An unannounced complaint investigation visit was conducted in response to an allegation that staff were mismanaging residents' medication logs.

The investigation found no substantial evidence or witnesses to support the allegation of medication log mismanagement. Medication records for three residents were reviewed and found to be complete, and interviews with staff confirmed proper medication administration procedures. The allegation was deemed unsubstantiated.

The complaint alleged staff mismanagement of residents' medication logs. The investigation was unannounced and included interviews with staff and residents, and review of medication records. The complaint was found to be unsubstantiated.

The visit was conducted as an initial complaint investigation related to an incident where a resident alleged an attempted sexual assault by another resident. The investigation was triggered by Complaint Control #31-AS-20230608081726.

The investigation found that the alleged incident could not be confirmed, but there was a lack of information and a plan to address the sexual behaviors of the involved resident. A deficiency was issued due to this lack of planning and documentation.

The complaint investigation was initiated due to an allegation by resident R1 that resident R2 had tried to rape them. The Executive Director stated the incident was alleged but could not be confirmed. An incident report and SOC341 were submitted. The deficiency was issued due to inadequate planning for R2's behaviors.

The visit was an unannounced complaint investigation conducted in response to an allegation that a resident choked another resident in care.

The investigation substantiated the allegation that resident #2 choked or physically grabbed resident #1 by the neck, causing injury that required emergency hospital evaluation. The incident was not isolated, with a prior related incident documented. Deficiencies were issued but cleared as of the visit date.

The complaint was substantiated. The incident involved an unwitnessed altercation on 6/6/2023 where resident #1 was choked by resident #2, resulting in hospital evaluation. Previous incidents involving the same residents were documented, confirming ongoing behavior issues and immediate health and safety risks.

The visit was a case management investigation triggered by a Special Incident Report (SIR) regarding a medication error where staff administered the wrong medication to a resident.

The facility reported that the medication error occurred due to confusion between residents with the same first name. The resident was sent to the hospital for evaluation and returned with no adverse effects. The facility implemented additional medication training and changed medication procedures to improve resident identification. A citation and repeat civil penalty were issued due to the incident.

The visit was complaint-related due to a medication error incident involving resident #1. The incident was substantiated as evidenced by the citation and repeat civil penalty issued.

An unannounced complaint investigation was conducted following a complaint received on 11/10/2022 alleging that a resident died due to staff administering the wrong medication.

The investigation substantiated the allegation that a resident (R1) was administered five incorrect medications prescribed to another resident, resulting in death. The facility failed to update resident appraisals, provide adequate medication training to staff, and did not obtain timely medical attention for the resident. Documentation and staff interviews confirmed lack of proper monitoring and follow-up after the medication error.

The complaint was substantiated. The investigation revealed that the resident died due to staff administering the wrong medication. Staff failed to monitor the resident's condition or obtain timely medical attention. A $500 immediate civil penalty was assessed for the violation resulting in the resident's death.

An unannounced complaint investigation was conducted due to allegations that a resident sustained multiple falls while in care.

The investigation found that Resident #1 had multiple falls resulting in bruising, skin tears, a nasal tip fracture, and rib fractures between September and October 2022. The facility was aware of the resident's decline but failed to update reappraisals or fall plans to manage the resident's changing condition, substantiating the complaint.

The complaint was substantiated. Resident #1 sustained multiple falls from 09/12/22 to 10/26/22 causing injuries including bruising, skin tears, nasal tip fracture, and rib fractures. The facility failed to update care plans or fall management despite awareness of the resident's decline.

The inspection visit was conducted as an unannounced complaint investigation following a complaint received on 2023-02-27 alleging that facility staff were not providing residents with their records.

The investigation found that the records requested were no longer needed and the complaint was retracted. The Executive Director reported that requests from attorney offices are handled by the facility's corporate legal team, and documentation confirmed the allegation was unsubstantiated.

The complaint alleged that facility staff were not providing residents with their records. The allegation was found to be unsubstantiated after investigation and communication with the complainant and facility staff.

The inspection was an unannounced complaint investigation conducted in response to allegations that staff were not assisting residents in a timely manner and that staff do not answer the phone when residents call for assistance.

The investigation included interviews with staff and residents, a physical plant walk-through, and testing of resident emergency pendants and pull cords. The allegations were found to be unsubstantiated, with no deficiencies issued during the visit.

The complaint investigation was unsubstantiated. Allegations included staff not assisting residents timely and not answering phones. Interviews and inspections showed staff responded within reasonable times and residents were satisfied with assistance.

An unannounced complaint investigation visit was conducted to investigate allegations that staff were not meeting residents' showering needs.

The investigation found that all hygiene needs were being met, residents were scheduled for showers at least two to three times a week or as needed, and caregivers were available to assist. The allegation was unsubstantiated due to insufficient evidence.

The complaint alleged that a resident did not shower for weeks. After interviews, observations, and document reviews, the allegation was found to be unsubstantiated.

The inspection was an unannounced complaint investigation visit conducted in response to multiple allegations received on 2022-11-18 regarding resident care and facility operations at Oakmont of Valencia.

The investigation found no substantiated violations; all allegations including resident care, staff training, meal service, and food supply were deemed unsubstantiated based on interviews, observations, and document reviews.

The complaint investigation was unsubstantiated. Allegations included failure to assist residents with incontinence needs, not following admission agreements, inadequate staff training, failure to ensure hearing aid use, not showering residents, late meal service, lack of full-time food service employee, not following menu plans, and insufficient food purchase. All were found unsubstantiated after thorough investigation.

The visit was an unannounced complaint investigation conducted in response to allegations received on 11/18/2022 regarding inadequate staffing, medication administration without physician's orders, and injury from over medication.

The investigation included interviews with staff, residents, and review of facility records. All allegations were found to be unsubstantiated based on interviews and document review, with no immediate health and safety issues observed during the visit.

The complaint included three allegations: 1) Facility does not have adequate staffing, 2) Staff administered medications to residents without physician's orders, and 3) Resident sustained an injury from being over medicated. All allegations were deemed unsubstantiated after investigation.

The visit was a Case Management inspection conducted to issue a deficiency related to a complaint control number 31-AS-20221110143440 regarding a failure to submit an Incident Report in a timely manner.

The licensee failed to submit a written Unusual Incident / Injury Report to the Community Care Licensing Department within seven days of the incident occurring on 11/06/22, which is a repeated violation resulting in a civil penalty of $1,000 and a citation.

The visit was triggered by a complaint control number 31-AS-20221110143440. The deficiency was substantiated as the licensee did not comply with reporting requirements for an incident that posed a potential health and safety risk to persons in care.

An unannounced complaint investigation was conducted following a complaint received on 06/28/2022 alleging that a resident sustained a severe fracture while in care.

The investigation found that a staff member left dementia residents unsupervised in a movie theater, which led to a resident falling and sustaining a severe hip fracture requiring surgery. The allegation was substantiated and a $500 immediate civil penalty was assessed.

The complaint was substantiated. The investigation included interviews with the resident's family, facility staff, administrator, former residents, and review of medical records. The staff member admitted leaving their post before being relieved, leading to unsupervised residents and the injury.

The inspection was an unannounced complaint investigation visit in response to an allegation of lack of supervision resulting in a resident being assaulted by another resident while in care.

The investigation found that resident R1 exhibited aggressive behavior and assaulted resident R2 without staff supervision, causing injury. The facility failed to protect residents from assault by R1, substantiating the complaint.

The complaint was substantiated. The allegation was that lack of supervision resulted in a resident being assaulted by another resident. Interviews and document review confirmed the facility failed to protect residents from assault by R1.

An unannounced case management visit was conducted due to an incident reported to licensing.

The facility was found non-compliant with medication documentation requirements, specifically medications were not documented on Centrally Stored Medication and Destruction Records (CSMDR), posing an immediate health and safety risk. A civil penalty of $1,000 was issued for this repeated violation.

Visit was triggered by an incident reported to licensing. Further investigation was determined to be needed and a return visit was planned.

Unannounced complaint investigation visit conducted due to an allegation that a resident sustained injuries from falls while in care.

The investigation found insufficient evidence to substantiate the allegation that the resident sustained injuries from a fall. Interviews and document reviews indicated the resident did not fall but folded in half and was caught by a caretaker, and the resident has a tendency to injure self.

The complaint alleged that on 10/18/22, a resident sustained injuries from falls while in care. The investigation included interviews with staff and witnesses and review of incident reports. The allegation was deemed unsubstantiated.

An unannounced complaint investigation was conducted to investigate the allegation that staff were inappropriately administering medication to a resident.

Based on interviews with the Executive Director and MedTech staff, and review of relevant documents, the allegation was found to be unsubstantiated. Staff were reported to follow residents' doctor's orders and maintain proper medication records.

The complaint alleged inappropriate medication administration by staff. The investigation included interviews and document review and concluded the allegation was unsubstantiated.

An unannounced complaint investigation visit was conducted to investigate the allegation that staff were retaliating against a resident.

Based on interviews and document review, the allegation of staff retaliation against the resident was found to be unsubstantiated. The facility did not issue an eviction letter nor retaliate against the resident.

The complaint alleged staff retaliation against a resident. The investigation included interviews with the Executive Director and staff, a physical plant tour, and review of relevant records. The allegation was deemed unsubstantiated.

An unannounced complaint investigation visit was conducted to investigate the allegation that the facility was malodorous.

Based on interviews with staff and observations during the visit, there was no evidence of a bad smell at the facility and no complaints were received regarding odor. Therefore, the allegation was unsubstantiated.

The complaint allegation was that the facility was malodorous. The investigation found insufficient evidence to verify the allegation, resulting in an unsubstantiated status.

The visit was conducted to address an incorrect deficiency report issued on 09/28/22 due to a technical/computer glitch issue.

During the visit, a new Case Management Deficiency report was issued with a corrected civil penalty of $1,000, replacing the previously issued incorrect penalty of $23,100.

The inspection was an unannounced complaint investigation visit triggered by complaints received on 07/21/2022 regarding residents' pull cords being in disrepair and staff not responding timely to call buttons, as well as allegations about visitor mask compliance and timely resident showers.

The investigation substantiated that residents' pull cords in the Memory Care Unit were in disrepair and non-operational, and staff response to call buttons was not timely. Other allegations regarding visitor mask compliance and timely resident showers were found unsubstantiated based on interviews and observations.

The complaint investigation was substantiated for allegations that residents' pull cords were in disrepair and staff did not respond timely to call buttons. Allegations that facility staff were not ensuring visitors wore masks and that residents were not showered timely were unsubstantiated.

Annual required visit and inspection of the facility conducted by Licensing Program Analyst Angela Panushkina to ensure compliance with licensing regulations.

The facility was found to be in compliance with no deficiencies cited. Observations included proper infection control, sanitary conditions in kitchen and resident rooms, proper medication documentation, and well-maintained common and outside areas.

This unannounced case management visit was conducted to address issues previously noted during a complaint investigation visit on 2022-09-14 regarding staff dispensing wrong medications not prescribed to a resident.

The facility failed to properly document prescribed and PRN medications on Centrally Stored Medication and Destruction Records (CSMDR), posing a potential health and safety risk to residents. A civil penalty of $23,100 was previously issued for this repeated violation.

The visit followed a complaint investigation alleging staff dispensed wrong medications not prescribed to a resident (Complaint Control # 31-AS-20220805133307).

An unannounced complaint investigation visit was conducted to investigate allegations that the facility was not following Covid-19 protocol.

The investigation found that the facility was following updated COVID-19 screening guidance from the CDC and California Department of Public Health, which no longer required visitor temperature checks or proof of vaccination, but the facility continued to encourage mask wearing. The allegation was determined to be unsubstantiated.

The complaint alleged that the facility was not following Covid-19 protocol. The investigation was unsubstantiated based on interviews and document review.

Unannounced complaint investigation visit conducted in response to allegations that staff dispensed wrong medications not prescribed to residents and falsified resident medication logs.

The investigation found no substantial evidence or witnesses to support the allegations. Medication records for three residents were reviewed and found to be complete and accurate. Therefore, the allegations were deemed unsubstantiated.

The complaint investigation was unsubstantiated based on review of medication records and interviews with staff. No evidence was found to support the allegations of medication errors or falsification of medication logs.

An unannounced complaint investigation visit was conducted in response to allegations received on 2022-01-03 regarding fecal smears and odor in a resident's room.

The investigation included a physical plant tour, staff interviews, and record reviews. The facility and randomly chosen resident rooms appeared clean and smelled fresh. Staff reported regular cleaning schedules and no complaints related to the allegations. Both allegations were deemed unsubstantiated.

The complaint investigation was unsubstantiated based on interviews, observations, and record reviews.

The visit was a Case Management visit conducted due to failure to timely submit several unusual incident/injury reports that occurred between 08/03/2022 and 08/22/2022.

The licensee failed to notify the Community Care Licensing Department regarding twelve incidents that occurred between 08/03/22 and 08/22/22 within the required seven days, posing a potential health and safety risk to persons in care.

An unannounced complaint investigation visit was conducted in response to an allegation that staff did not prevent a resident from physically abusing another resident.

The investigation found no evidence of resident-to-resident abuse; instead, it was determined that resident #1 was aggressive and abusive towards staff members. The allegation was deemed unsubstantiated.

The complaint alleged that staff failed to prevent a resident from physically abusing another resident. After interviews with staff and residents and review of records, the allegation was found unsubstantiated.

Unannounced complaint investigation visit conducted due to allegations that staff did not inform the responsible party of an unusual incident and did not prevent a resident from wandering away from the facility.

The investigation substantiated both allegations: staff failed to notify the responsible party in writing in a timely manner about the resident's elopement incidents, and staff failed to prevent the resident from wandering away from the facility, posing immediate health and safety risks.

The complaint investigation was substantiated. The resident eloped from the Memory Care Unit on 08/04/2022 and was found minutes later. Staff did not notify the responsible party timely in writing, and another elopement incident was reported on 08/26/2022 with undetermined circumstances.

An unannounced complaint investigation was conducted regarding allegations that Resident 1 sustained an unexplained injury for which staff failed to obtain timely medical care and that due to staff neglect Resident 1 sustained severe facial injuries.

The investigation found sufficient evidence to substantiate the allegations that staff failed to obtain timely medical care for Resident 1's unexplained injury and that neglect caused severe facial injuries. However, the allegation of questionable death was unsubstantiated based on death certificate review.

The complaint alleged that Resident 1 sustained an unexplained injury and staff failed to obtain timely medical care, and that due to staff neglect Resident 1 sustained severe facial injuries. The investigation was substantiated for these allegations. The allegation of questionable death was unsubstantiated.

An unannounced complaint investigation visit was conducted to investigate multiple allegations including insufficient staffing, failure to provide activities, hygiene needs, adequate food service, safe environment, and COVID-19 precautions.

All allegations were found to be unsubstantiated based on interviews with residents and staff, observations of the facility environment, activities, food service, hygiene care, and COVID-19 precautions.

The complaint investigation was triggered by allegations of insufficient staffing, lack of activities, unmet hygiene needs, inadequate food service, unsafe environment, and failure to take COVID-19 precautions. After review and interviews, all allegations were deemed unsubstantiated.

The inspection was an unannounced complaint investigation visit triggered by allegations received on 2022-01-03 regarding medication administration, staff training, and facility signage.

The investigation substantiated that facility staff did not properly document medication administration, staff training was inadequate, and required signage was not properly posted. An allegation that the facility did not serve nutritious foods was unsubstantiated.

The complaint investigation was substantiated for allegations that facility staff did not give residents their medications correctly, staff were not adequately trained, and facility signage was not properly posted. The allegation that the facility does not serve nutritious foods was unsubstantiated.

An unannounced complaint investigation was conducted due to an allegation that a resident was allowed to leave the facility without staff supervision.

The investigation substantiated the allegation that a resident exited the facility unsupervised and walked down the street before being returned by a family member of another resident. The facility failed to ensure the safety of the resident, posing an immediate health and safety risk.

The complaint was substantiated based on the finding that a resident left the facility without staff supervision and was found outside by a family member of another resident.

An unannounced required pre-licensing visit was conducted due to a change in corporation for the facility.

The facility was found to be clean, sanitary, and in compliance with Title 22 Regulations with no health and safety hazards preventing license approval. Some staff files were missing employee rights documentation, and the administrator was instructed to update and complete these files.

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