Oakmont of Mariner Point

On 3/4/2026 at 3:35PM, Licensing Program Analyst (LPA) G. Luk arrived unannounced to conduct a case management visit in regards to death report received for R1. LPA met with Health Services Director, Paolo Valera and explained the purpose of the visit. Death report revealed that staff check on R1 when family was visiting and R1's family informed staff that R1 passed away. 911 was contacted. During visit, LPA reviewed R1's physician's report, care plan, and care notes. R1 was not on hospice care. R1 has diagnosis which includes hypertensive heart disease and Alzheimer's disease. No deficiencies are being cited on this date. Exit interview conducted. A copy of this report provided.

Facility Type: RCFE Application Type: CHOW Capacity: 0080 Census (if any clients in care): COMP II by CAB successfully completed Method: Telephone call COMP II Participant: GERRY VADNAIS Applicant/administrator participated in COMP II via telephone call with the analyst at CAB. Identification of the applicant and administrator was verified by photo ID . During COMP II, applicant and administrator confirmed the understanding of Title 22. Component II was successfully completed. During COMP II, CAB analyst confirmed Applicant/Administrator’s understanding of following areas: 1. Facility operation: License type, client/resident populations, and program 2. Staff qualifications and responsibilities 3. Applicant and Administrator qualifications 4. Program policy: Abuse, admission agreement, medication management, reporting incidents to CCL, restricted & prohibited conditions 5. Grievances, Complaints, Community resources 6. Physical plant, food service 7. Application document review and technical assistance: Criminal record clearance, Health screening, Fire clearance, First Aid/CPR certificate, Administrator certificate, Financial verification, Pre-licensing inspection, Compliance history, Control of property

On 3/4/2026 at 3:35PM, Licensing Program Analyst (LPA) G. Luk arrived unannounced to conduct a case management visit in regards to an incident report. LPA met with Health Services Director, Paolo Valera and explained the purpose of the visit. Based incident report, resident (R1) exited the back door around 5:30PM and alarm was triggered via wander guard. Staff immediately responded by searching for R1 and found R1 in front of a restaurant. During visit, LPA interviewed staff and reviewed R1's file. LPA observed R1's physician's report stated that R1 can leave the facility unassisted. R1's care plan stated resident is to wear safety bracelet when in Assisted Living. LPA advised facility to update R1's physician's report due to R1's change in condition. Health Services Director is in communication with R1's family and will look into obtaining an updated physician's report. No deficiencies are being cited on this date. Exit interview conducted. A copy of this report provided.

On 11/21/24 R1 was placed on Hospice and on 2/19/25 R1 moved to Memory Care for the last time. R1 was discharged from the facility on 3/17/25 to a 6 bed RCFE operated by W1. S1, S2 and W2 all stated that R1’s health was in decline during her time at the facility. Allegation: Resident sustained unexplained laceration W1 was concerned about the open sores on R1’s heels and considered them to be a laceration. W2 stated that staff were monitoring the condition of R1’s heels on a daily basis. Staff would try to get R1 to lie in bed with her feet elevated so the heels were not in contact with the bed sheets, but she often refused. W2 also stated that she would not consider the sores on R1’s feet to be unexplained laceration. Allegation: Staff did not seek timely medical treatment for resident W1 had no specific information regarding this allegation stating that she “had a feeling” that the residents at the facility were being neglected and that it should be investigated. During the time period outlined in the complaint R1 was on Hospice and receiving regular visits from the Hospice nurse (W2). W2 stated that she was in contact with R1’s physician as needed and felt that R1 received all the medical care she needed in a timely manner. Allegation: Staff are not providing adequate assistance to resident during feeding times W1 never observed R1 during mealtimes but did observe food on her mouth and clothing. S1 and S2 state that R1 would often refuse to eat or eat very little. LPA reviewed R1’s care notes from January 2025 to March 15, 2025, and saw several entries stating that “R1 didn’t eat much,” and “R1 refused breakfast.” Allegation: Staff are not properly supervising residents who may be a fall risk W1 stated that on one of her visits to the facility she found R1 lying in bed with both legs hanging on the left side of the bed with no supervision and the bedroom door shut. S2 stated that residents in the Memory Care Unit who are identified as a fall risk are put on an increased level of supervision, these residents are checked hourly or more as needed. R1 was considered a fall risk and care notes reviewed by LPA document that staff were checking on R1 on a regular and routine basis and would occasionally find R1 trying to get out of her bed or wheelchair in the same manner as described above. ***report continues on LIC9099C*** 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 ***report continues from LIC9099C*** Allegation: Staff are not meeting residents’ dietary needs W1 stated that between her visits to the facility it appeared that R1 had lost weight, and she felt that the staff weren’t monitoring R1 close enough during mealtimes to ensure that she eats her food. W1 asked facility staff, names unknown, about R1’s diet and staff replied that R1 doesn’t eat much and that they try their best, but they can’t force her to eat. S2 stated that R1 had a very poor appetite and that she often would refuse to eat. S2 also stated that staff would offer R1 dietary supplement drinks which R1 would drink occasionally. This agency has investigated the above complaints. We have found that the complaints are unsubstantiated. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are UNSUBSTANTIATED. Exit interview conducted, a copy of this report provided.

Staff mismanage residents’ medications. LPA reviewed medication administration records (MARs) for R1, R2 and R3 and found no evidence that any of their medications were mismanaged. All 3 residents received their medications as prescribed and properly documented on the MAR. This allegation in unsubstantiated. Staff do not provide adequate supervision for residents. LPA interviewed S1 and S7 who are responsible to manage transportation for residents who need assistance in getting to their doctors’ appointment. Both stated that residents are either transported by family or in the facility van with staff accompanying them if needed. Both stated that no residents with dementia are ever put in an Uber to be transported by themselves to a doctors’ appointment. This allegation in unsubstantiated. This agency has investigated the above allegations. We have found that the allegations were unsubstantiated. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are UNSUBSTANTIATED . Exit interview conducted, a copy of this report provided.

At the facility LPA reviewed R1’s file and interviewed S1 and S2 and toured the memory care unit. R1 was admitted to the facility on 3/23/2024, admitted to hospice on 4/08/24 and passed away on 7/23/24. S1 stated that she never heard any complaints about R1’s care from R1’s Responsible Party. S1 did state that she heard that the RP was rude to the facility staff and was very disruptive during her visits to the Memory Care Unit where R1 resided. S2 stated that R1 was monitored closely by the Memory Care Unit staff and was never left unsupervised for extended periods of time. R1 did develop several wounds while in care due to R1 being bed bound while also being very restless. The wounds were treated as prescribed and never developed past Stage 1. S2 further stated that R1’s was given bed bath’s 3 times weekly. LPA confirmed this by reading the care notes in R1's chart. Allegation: Staff left resident without care and supervision for an extended period of time. R1 was visited by W1 on a daily basis. W1 always observed that staff were attending to R1. R1 also had visits from Hospice 3 - 4 times a week and a Nurse twice weekly. Review of chart notes do not document any concerns about R1’s care and supervision. This allegation is unsubstantiated. Allegation: Resident in care developed a wound due to lack of staff supervision. R1 did develop wounds while in care. S2 stated that it is not uncommon for bed bound residents on hospice to develop these types of wounds. S2 further stated that R1’s wounds were not due to a lack of staff supervision but due to R1’s deteriorating condition. This allegation is unsubstantiated. Allegation: Staff did not ensure that resident's hygiene needs were met while in care. Review of R1’s chart and interview with S2 revealed that R1 was receiving assistance with his activities of daily living on a daily basis and receiving bed baths 3 times weekly. This allegation is unsubstantiated. ***report continues on LIC9099C*** 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 ***report continues from LIC9099C*** Allegation: Staff did not ensure that resident was fed while in care. Over the course of R1’s time at the facility (4 months) R1 went from being on a regular diet and able to feed himself independently to being placed on a puree diet where he needed staff assistance. S2 stated that R1 simply lost to desire to eat and that R1 always had a staff person assigned to him to assist during meals. This allegation is unsubstantiated. Allegation: Staff did not follow personal hygiene and sanitation practices. LPA toured Memory Care Unit and observed all staff wearing gloves and masks. Hand washing signs are posted by each sink. S2 stated that all staff receive training on personal hygiene and sanitation practices. LPA asked 2 memory care staff when they are required to wash their hands, both replied "all the time." This allegation is unsubstantiated. This agency has investigated the complaint alleging staff left resident without care and supervision for an extended period of time, resident in care developed a wound due to lack of staff supervision, staff did not ensure that resident's hygiene needs were met while in care, staff did not ensure that resident was fed while in care and staff did not follow personal hygiene and sanitation practices. We have found that the complaint was unsubstantiated. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegation is UNSUBSTANTIATED . Exit interview conducted, a copy of this report provided.

Facility staff not meeting Residents incontinent care, Facility not meeting Residents needs due to insufficient staffing LPA reviewed facility’s Urinary Incontinence policy. The policy states that residents with urinary incontinence will receive appropriate care by facility staff. LPA reviewed the staff schedule for Sunday 7/16/2023. On 7/16/23 there was 1 med tech and 1 care staff assigned to work in memory care and 2 other care staff were transferred from assisted living to memory care to provide additional support. The Memory Care Director was also on site. The memory care census on this weekend was 22. Facility does not document incontinence care however there were sufficient staff in the memory care unit on 7/16/23 to provide appropriate care. This agency has investigated the complaints alleging facility air conditioning is in disrepair, facility staff not meeting residents incontinent care and facility not meeting residents needs due to insufficient staffing. We have found that the complaints were unsubstantiated. Although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are UNSUBSTANTIATED . Exit interview conducted, a copy of this report provided.

On 9/17/24 at 10:30 AM, Licensing Program Analyst (LPA) Greg Clark arrived unannounced to conduct 1-Year Annual Required inspection. LPA met with Jannelle Douglas, Administrator and explained the purpose of the visit. LPA toured the facility including but not limited to 4 residents’ apartments, bathrooms, multiple activity rooms, kitchen, common area and courtyard. There are no bodies of water observed. LPA observed lighting in all rooms are adequate for the comfort and safety of the residents. Hallway temperature was maintained at 70 degrees F. The hot water temperature at a sink in the kitchen was measured at 117.2 degrees Fahrenheit. Residents’ bathrooms are equipped with grab bars and non-skid mats. There is a minimum of one week supply of nonperishable and 2-day of perishable foods. Centrally stored medications, sharps and toxic are locked and inaccessible to residents in care. Smoke detectors and carbon monoxide detectors were in operating condition during visit. Fire extinguisher was last serviced on 1/03/24. Emergency Disaster Plan was last posted on 7/15/24. First aid kit was observed to be complete. Emergency disaster drill was last conducted on 6/15/24. LPA reviewed 5 residents records and 5 staff records, and all were complete. LPA also reviewed a sample of resident’s medications. No deficiencies cited during visit. Exit interview conducted and a copy of this report provided.

This agency has investigated the complaint alleging the facility call system is in disrepair. We have found that the complaint was UNSUBSTANTIATED. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED. Exit interview conducted, a copy of this report provided.

On 9/22/23 at 11:10 a.m., Licensing Program Analyst (LPA) G. Clark arrived unannounced to conduct 1-Year Annual Required inspection. LPA met with Caroline Frangieh, Interim Administrator and explained the purpose of the visit. The facility’s fire clearance was approved for 80 of which 80 may be non-ambulatory and 6 may be bed-ridden. LPA toured the facility including but not limited to 4 residents’ apartments, bathrooms, multiple activity rooms, kitchen, common area and courtyard. There are no bodies of water observed. LPA observed lighting in all rooms are adequate for the comfort and safety of the residents. Hallway temperature was maintained at 70 degrees F. The hot water temperature in the kitchen was measured at 118.5 degrees Fahrenheit. Residents’ bathrooms are equipped with grab bars and non-skid mats. There is a minimum of one week supply of nonperishable and 2-day of perishable foods. Centrally stored medications, sharps and toxic are locked and inaccessible to residents in care. Fire extinguisher was last serviced on 1/14/23. First aid kit was observed to be complete. Fire drill was last conducted on 6/29/23. At 11:35 p.m., LPA reviewed 5 residents records. At 12:05 p.m., LPA reviewed 5 staff records and of 5 have current first aid training and associated to the facility. At 12:45 p.m., LPA reviewed a sample of resident’s medications. Updated copies of the following documents were requested for facility file and are to be submitted to CCL by 9/29/23: LIC610E No deficiencies cited during visit. Exit interview conducted and a copy of this report provided.

On 2/16/23 at 12:30 p.m., Licensing Program Analyst (LPA) Greg Clark arrived unannounced to conduct a case management visit due to receiving an incomplete LIC624.. LPA met with Melissa Melek, Regional Director and explained the purpose of the visit. During the visit LPA interviewed the facility's Health Services Director and reviewed the facility's internal Incident Reprot. LPA observed on the internal Incident Report that proper notifications were made to the resident's family. No deficiencies cited during visit. Exit interview conducted and a copy of this report provided.

Page 2 Review of shower records showed residents' schedule of showers and signed by the assigned staff when done. All staff interviewed stated they assist residents with ADLs. S4 and S5 denied waiting for hospice staff to provide assistance with ADLs. R1 stated staff assist her as needed. Allegation: Facility staff withhold food and water from R1. It was alleged that S4 and S5 withhold food and water from R1. Seven out of 8 staff interviewed stated they never withhold food and water from R1. S4 and S5 denied withholding food and water from R1. R1 stated staff gives her whatever she wants. Allegation: Facility staff prohibit R1 from using facility phone. it was alleged that every time R1's family member calls the facility, staff will say resident has dementia. LPA interviewed R1 who stated she has cell phone, and she can use the facility phone if she wants. All staff interviewed stated facility has land line phone and cordless phone and residents are allowed to use. Incoming calls are given to the residents. LPA observed on 10/20/21 a resident using the facility land line phone. Allegation: Facility staff are verbally abusive to R1. It was alleged that when R1 ask for water, S4 and S5, tell R1 to go and drink water from the toilet bowl. S4 and S5 denied the allegation. The other 5 staff interviewed also denied the allegation, and stated either they have not work with S4 and S5 or never heard them tell R1 the allegation. R1 stated the staff were never abusive to her. Allegation: Facility staff fail to assist R1 with incontinence care. It was alleged that S4 and S5 wait for hospice aide to change R1's diaper. During initial visit, LPA observed R1 clean and no smell of urine. R1 stated the staff assist her as needed. The 7 staff interviewed stated residents are changed 2 to 3x during shift, promptly and as needed. S4 and S5 denied waiting for hospice aide to change R1's diaper. ...continued on 9099C (page 3) 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 Page 3 Allegation: Facility was short staffed. All 7 staff stated they are able to do their duties. There were times when staff may call off or leave early, but management called for back-up and at times worked on the floor. One out of 7 staff interviewed stated this has changed recently and management is cutting staff hours to save on budget. Based on all information gathered and due to LPA unable to obtain information from R1's family member and hospice staff, the 6 allegations are closed as unsubstantiated. A finding that the complaint is unsubstantiated means that although the allegations may have happened or are valid, there are not a preponderance of the evidence to prove that the alleged violations occurred. No deficiency cited. Exit interview conducted and copy of this report provided.

On 2/16/23 at 12:00 p.m.,Licensing Program Analyst (LPA) Greg Clark arrived unannounced to conduct a case management visit on this date to verify if an individual is currently employed at the facility. LPA meet with Melissa Melek, Regional Director and explained the purpose of the visit. LPA reviewed staff roster and interviewed staff. Based on evidence obtained during today’s visit, the LPA has verified the individual is not present, employed, or residing at the facility. LPA has advised to disassociate the individual from their roster. No deficiencies cited during visit. Exit interview conducted and a copy of this report provided.

On 11/19/21 at 2:15 pm Licensing Program Analysts (LPAs) G. Clark and L. Francisco arrived unannounced to conduct Infection Control Inspection. LPAs met with Administrator, Avon Nguyen and explained the purpose of the visit. During the Infection Control Inspection, LPAs toured facility including but not limited to front entrance, screening station, hand washing stations, bedrooms, common areas, kitchen and backyard. Facility has a sufficient 2-day perishable and one week non-perishable food supply. Visitors policy is posted on the front entrance. There is one central entry point for universal screening for staff, residents and visitors. A sign-in policy, thermometer and hand sanitizer were observed at screening station. Cough/sneeze etiquette, social distancing and hand washing posters were observed. Facility staff were observed to be wearing proper PPE. Facility has a 30-day supply of PPEs maintained at central location and easily accessible for staff. Facility has a mitigation plan and maintains record of routine screening for residents and staff. No deficiencies cited during visit. Exit interview conducted and a copy of this report provided.

On 9/7/2021 , Licensing Program Analyst (LPA) L. Ibo arrived unannounced to conduct a pre-licensing inspection due to a change of ownership. LPA met with Nurse Avon Nguyen, Administrator Gerry Vadnais was called to inform the purpose of the visit, Administrator gave permission to LPA to conduct the inspection with Nurse Avon Nguyen. Facility has an approved fire clearance for 6 bedridden residents on any room on first floor and second floor and 74 non ambulatory residents. Last fire inspection was conducted on August 4,2021. LPA inspected the facility including but not limited to 7 resident rooms common areas, kitchen,activity room, dining and outside areas. Hot water measured at 117.2 degrees Fahrenheit. Fire extinguisher was observed around the common areas of the facility with inspection tags dated January 3 rd 2021. There was sufficient supply of perishable and non-perishable foods. First aid kit was complete. ....Continue to LIC809C.... 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 LPA's observed the following during inspection: At 11:46 AM on room 317, R1’s medication was observed unlocked and accessible to R1. LPA confirmed via records review that facility is managing the medication for R1. At 11:54 AM on room 227 medication was observed on R2’s bathroom which was accessible to resident in care. At 11:57 AM on room 229 LPA observed poisonous disinfectant spray was found unlocked which was accessible to R3 or to resident in care. At 12:09 PM on room 106, LPA observed poisonous disinfectant was found unlocked which was accessible to R4 or to resident in care. . Component III was waived. LPA is not recommending facility for license until all deficiencies are cleared. This Pre-Licensing report will be submitted to the Central Application Branch (CAB) for review. Exit interview conducted with Applicant/nurse..