Oakmont of Orange.

R1 was using their walker to walk over to the dining room for dinner with their daughter when they fell back and hit their head. Charting Notes do not indicate if R1’s pendant was pressed at that time or how staff was alerted of R1’s fall. Interviews were conducted with one witness, two staff, and six residents. During their interview, R1’s daughter, Witness 1 (W1) stated that on October 16, 2025 at 4:00 a.m., R1 called them crying and stated they had pressed the call button in their bathroom due to having fallen and had waited for staff to arrive. Per W1, R1 informed them they got back in bed because no one came and had fallen asleep. W1 stated R1 woke up again because their head was hurting. Per W1, they told R1 to call 911 and stated it was R1 who had called 911 “as far as” they knew. W1 stated they then called the front desk to inform them of R1’s fall and questioned why staff had not gone to check on R1. W1 stated staff apologized and stated they thought it was a “false alarm” because R1 had never pressed their call button before. W1, however, was unable to identify staff alleged to have stated they thought it was a “false alarm.” Per W1, on October 19, 2025, they had been present at the time of R1’s fall and had pressed R1’s pendant, but no one came, so they pressed it again and no one came until they called the front desk and were subsequently informed staff were tending to another resident emergency, and paramedics were already on-site. R1 is no longer a resident at the facility. Three separate attempts were made to reach R1 by phone, however, R1 could not be reached to confirm or deny allegation. During their interview, S1 stated that on October 16, 2025 at approximately 4:00 a.m., they received a call from W1 notifying them that R1 had an unwitnessed fall in their bedroom and had been pressing their call button. S1 stated they did not know how long it had been since R1’s fall or how many times R1 had pressed their call button. Per S1, if a resident keeps pressing their pendant and staff go to clear another resident’s call, the call system will inevitably clear their call as well. S1 stated that upon responding to R1’s room they found R1 sitting on the edge of their bed. Per S1, R1 informed them they had gotten up to go use the restroom and had fallen and hit their head on the television stand and that is when paramedics were called. S1 stated they could not recall ever personally telling W1 they had not checked on R1 due to R1 never pressing their pendent nor did they recall any other staff making that statement. S1 stated they had called the paramedics as soon as R1 informed them that they had hit their head and paramedics arrived between “five to six minutes” later. During their interview, S2 stated on October 19, 2025, R1 was walking with their walker with the assistance of W1, when they fell back and hit their head. Per S2, W1 reported pressing R1’s pendant, however, S2 was tending to another resident emergency at the time and stated they were unsure how long it had taken for them to respond but estimated "it could have been ten to fifteen minutes." (Cont. LIC9099-C) 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 Per S2, once they were informed R1 had hit their head, paramedics on-site were called to assess R1 and transported them to the hospital. During interview, Resident 2 (R2) and Resident 3 (R3) stated that in the event they need assistance they are able to alert staff using their pendant, and staff respond within minutes. Per R2 and R3, emergency services have been called for them personally on at least one occasion and stated they were contacted immediately and an ambulance arrived without delay. During their interview, Resident 4 (R4) stated their pendant has been tested by staff and they were informed it tested operational; however, they believe it often malfunctions and therefore, they use their personal cell phone to call for assistance and staff "come right away." R4 denied having any knowledge of any delays in staff seeking medical care for residents. During their interview, Resident 5 (R5) and Resident 6 (R6) stated they have not personally required emergency services be called. Per R5, they do not need staff assistance and in the event they accidentally press the pendant around their neck, staff "come right away" and if they are not in their room, staff will find them walking around the facility and ask if they need assistance. Per R6, in the event they need assistance, they call the front desk using their personal cell phone or use the pendant around their neck and staff arrive immediately. Based on record review of R1's Charting Notes and due to allegation being uncorroborated during interviews conducted, the Department is unable to determine if Facility did not respond to a resident's call light in a timely manner or if Facility did not call medical services in a timely manner. Although the above 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 at this time the above allegations are unsubstantiated. An exit interview was conducted and copy of this report was provided at the end of the inspection.

Based on the review of R1's service plan dated June 19, 2024, R1 was provided complete assistance with toileting according to schedule, needs, and requests. Based on the review of R1's care notes, there were written documentation providing brief changes on May 12, 13, 30, 31, 2024, and during the nocturnal shifts. R1 also refused to use the toilet and requested brief changes in bed on May 30, 2024. Based on an interview with a witness, R1 alleged "waiting for hours" when staff was called for assistance. Care notes reveal that R1 was checked on "multiple times throughout shifts" even though R1 "voiced complaints of staff not checking in overnight." Based on the interviews with eight residents who resided at the facility in 2024, none of the residents are incontinent. Three of eight residents required assistance with toileting which also aligned with their care plans at the time; however two of three residents that required toileting, confirmed toileting assistance was provided as needed per their requests. LPA was unable to qualify the statement of the third resident due to their medical condition, and two of three staff denied the allegation while the third indicated not providing care to R1 at the time. Regarding the allegation, Facility staff did not assist resident with showering as needed, it is alleged that R1 received sporadic showers. Based on the review of R1's service plan, complete assistance with showering/bathing was provided four times a week for R1. There were no documentation regarding showers per the care notes. However, based on the interviews with eight residents who resided at the facility in 2024, seven confirmed showers were provided timely which aligned with their individual plans. LPA was unable to qualify one resident due to their medical condition. Two of three staff denied the allegation while the third staff indicated not providing care to R1 at the time. Regarding the allegation, Facility staff handled the resident in a rough manner, it is alleged that the handling of R1 was "roughed up." Based on the interviews, seven of eight residents who resided at the facility in 2024 denied experiencing aggressive handling also denied by two of three staff who were employed at the time. However, one resident confirmed one caregiver was rough in the way they assisted them during transfers. The remaining one staff did not provide care to R1 at the time. Based on interviews and record review, 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, all allegations are deemed UNSUBSTANTIATED. An exit interview was conducted with Health Services Director Angela Boyd, and a copy of this report was provided at the end of the visit.

Per W1, when they are personally present at the facility, staff routinely check on R1, however, stated they did not know if staff routinely check on R1 when they are not present at the facility. During their interview, R1 denied ever sustaining a fall and stated if they did, “it was a long time ago” and could not remember. LPA obtained a copy of Incident Report (LIC624) which indicated that on May 11, 2024, R1 had an unwitnessed fall in their bedroom and had been found as a dining room tray was being delivered to their room. LIC624 identifies S1 as the person who observed the incident, however, S1 is no longer employed at the facility. Three separate attempts were made to reach S1 by phone, however, S1 could not be reached to confirm or deny the allegation. LPA obtained a copy of a separate LIC624, which indicated that on October 8, 2024, R1 had an unwitnessed fall in their bedroom and had been found on the floor by Staff 2 (S2) as they were conducting routine checks. During their interview, S2 stated they could not recall specific details regarding the incident, however, stated routine checks are conducted for R1 during shifts and R1 is also escorted to meals and activities by staff, which enables staff to conduct additional checks on R1. LPA obtained a copy of Individualized Service Plan (ISP) for R1, which indicates R1 is at moderate risk for falling, and is to be provided with a status check each shift and escorted to meals and activities. Per ISP, fall management protocol consists of ensuring R1 is using assistive mobility devices at all times, reminding and encouraging R1 to use pendant to call for staff assistance, and staff continuing with frequent check-ins. During their interview, Staff 3 (S3) stated they did not have any knowledge regarding R1’s fall on May 11, 2024 or October 8, 2024, however, stated that due to R1’s moderate risk for falling, staff are to conduct status checks. Per S3, status checks are conducted every two to three hours and consist of staff physically observing the resident to ensure they have not fallen. During the course of the investigation, LPA observed R1 being checked on by care staff on at least two occasions. Based on record review of R1’s Individualized Service Plan and LIC624, and due to allegation being uncorroborated during interviews conducted, the Department is unable to determine if Resident sustained multiple falls while in care due to staff neglect. Although the above 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 at this time the above allegation is unsubstantiated. An exit interview was conducted and copy of this report was provided at the end of the inspection.

Six months later R1 was assessed again for Fall Risk Evaluation and scored a 3, indicating Minimal Risk of falling. R1’s charting notes stated that R1 had a fall on October 28, 2022 , where resident tripped on a rug but got up immediately and underwent a Physical therapy assessment where therapist noted R1 is alert oriented x3 and demonstrates poor safety awareness due to impulsive movement. Physical Therapist recommended R1 to improve safety by using an assistive device such as cane or walker. On 7/3/2023 Hospital Records stated that R1 had tripped over themselves causing an unwitnessed fall. R1 went to hospital. On 7/12/2023 Facility conducted a assessment on R1 due to a change in condition with behaviors and mobility issues. Residents Needs and Service Plan was updated same day 7/12/2023 indicating R1 needs assistance in grooming, dressing, assist with transfers, frequent checks throughout shifts and documentation by staff. Per staff interviews, one of four staff members recalled R1 and stated that they were in assisted living and remembers R1 being independent of their Activities of daily living (ADL’s) for a long time and it wasn’t till the last few months of R1 requiring assistance due to mobility issues. Regarding Staff neglected resident while in care: Based on records reviewed, R1 was independent up till their unwitnessed fall on 7/3/2023. R1 had charting notes dated from 1/16/22 to 7/10/2023, where care providers logged notes on type of care or behaviors monitored by staff. R1 also had a home health agency that came out weekly to monitor R1’s foot sore on left foot. On 6/19/2023, R1 was admitted to Hospice due to generalized weakness. Hospice notes also indicated type of care provided. Per staff interviews, four of four staff members stated that Residents who are a fall risk are typically checked in on & monitored every half hour. One of four staff mentioned that R1 was fairly independent and had a change of condition towards their last month. Per SOC 341, R1’s family member stated that they had no concerns regarding care provided at facility. Based on information gathered from complaint, the allegations Resident sustained multiple falls while in care and Staff neglected resident while in care were deemed Unsubstantiated meaning that although the allegation may have happened or is valid, there is no preponderance of evidence to prove the alleged violation did or did not occur as reported. An exit interview was conducted with Activity Director Rebecca Lint and copy of report was provided.

S1 is no longer employed at the facility and three separate attempts were made to reach S1 by phone, however, S1 could not be reached to confirm or deny the allegation. Interviews were conducted with one witness, eight facility residents, and four staff. During their interview, R1’s responsible party, Witness 1 (W1), attributed R1's fall to their medical diagnosis and stated they were unsure if R1 had sustained a laceration or skin tear as a result of the fall. W1 stated they believed there could have been a lapse of about "15 minutes" between R1’s fall and R1 being found on floor, however, stated they did not believe it was two hours. Per W1, they had no concerns regarding the care provided to R1 by the facility. During their interview, seven of eight residents denied staff not providing adequate supervision and stated that in the event they need assistance they are able to alert staff using their pendant, and staff respond within minutes. One of eight residents stated their pendant has been tested by staff and they were informed it tested operational; however, they believe it often malfunctions and therefore, they use their personal cell phone to call for assistance and staff "come right away." During their interview, four of four facility staff denied having any knowledge of R1’s fall or injury and denied having knowledge of R1 or any other resident sustaining a fall with a two hour lapse in supervision by staff. Based on record review of R1's Care Notes and due to allegation being uncorroborated during interviews conducted, the Department is unable to determine if Facility staff did not provide adequate supervision resulting in resident being injured. Although the above 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 at this time the above allegation is unsubstantiated. An exit interview was conducted and copy of this report was provided at the end of the inspection.

Licensing Program Analyst (LPA) Claudia Gutierrez made an unannounced visit for the purpose of conducting a Required/Annual Inspection. LPA met with Health Services Director (HSD) Angela Boyd and explained the purpose of the inspection. During the inspection, LPA and HSD conducted a tour of the inside and outside of the facility, common areas, resident rooms, kitchen, dining rooms, activity rooms, and observed the following: This is a three-story building with a parking garage on the basement floor. The first floor is used primarily for memory care, and the second and third floor are designated for assisted living. All resident bedrooms had the required furnishings. LPA observed all resident beds had linens and blankets. There are two separate courtyards, and both contain shaded sitting areas. LPA observed residents socializing in common areas and resting in their respective bedrooms. Bathrooms were observed to be free of debris and mildew, and faucets and toilets were operational. Water temperature tested between 105.4 - 116.9 degrees Fahrenheit. LPA observed the facility has a 2-day supply of perishables and a 7-day supply of non-perishable food as required by regulations. Smoke detectors and carbon monoxide detectors tested operational. A fire extinguisher was observed along every facility hallway with service tag dated March 20, 2025. Facility appliances, including gas stove, refrigerator, freezer, laundry washer and dryer were inspected and observed to be operable. Toxic chemicals, cleaning solutions, and disinfectants were observed to be inaccessible to residents. LPA reviewed nine resident files and four staff files. Based on the observations made during today’s inspection, no deficiencies are being cited per Title 22 Division 6 of the California Code of Regulations. An exit interview was conducted, and a copy of this report was left at the facility.

On this day, Licensing Program Analyst (LPA) Edward Kim made an unannounced Case Management visit to the facility to serve an Immediate Exclusion Order to staff member S1. LPA met with Executive Director Anna Pastores and explained the purpose of the visit. The Immediate Exclusion Order was explained to the Executive Director. The Order to Individual for Immediate Exclusion from Facility letter and the Order to Licensee/Facility of Immediate Exclusion from Facility letter were both served to ED Pastores. ED Pastores stated they understood the Order and said they had no additional questions. Facility will adhere to the exclusion order and not schedule S1 for future shifts. An exit interview was conducted, and a copy of this report and LIC811 was provided to Executive Director Anna Pastores.

Licensing Program Analyst (LPA) Claudia Gutierrez made an unannounced visit for the purpose of conducting a Required/Annual Inspection. LPA met with Business Office Director (BOD) Dianna Kuhn and explained the purpose of the inspection. Executive Director (ED) Anna Pastores arrived at approximately 9:00 a.m. During the inspection, LPA, ED, and Health Services Director (HSD) Alyson Womack conducted a tour of the inside and outside of the facility, common areas, resident rooms, kitchen, dining rooms, activity rooms, and observed the following: This is a three-story building with a parking garage on the basement floor, first floor is used primarily for memory care, and the second and third floor are designated for assisted living. All resident bedrooms had the required furnishings. LPA observed all resident beds had linens and blankets. There are two separate courtyards and both contain shaded sitting areas. LPA observed residents participating in leisure activities, including live music, and resting in their respective bedrooms. Bathrooms were observed to be free of debris and mildew, faucets and toilets were operational. Water temperature tested between 112.6 - 120.5 degrees Fahrenheit. LPA observed the facility has a 2-day supply of perishables and a 7-day supply of non-perishable food as required by regulations. Smoke detectors and carbon monoxide detectors tested operational. At least two fire extinguishers were observed in every facility hallway with service tags dated March 29, 2024. Facility appliances, including gas stove, refrigerator, freezer, laundry washer and dryer were inspected and observed to be operable. Toxic chemicals, cleaning solutions, and disinfectants were observed to be inaccessible to residents. LPA reviewed nine resident files and six staff files. LPA interviewed six residents and four staff. Based on the observations made during today’s inspection, no deficiencies are being cited per Title 22 Division 6 of the California Code of Regulations. An exit interview was conducted, and a copy of this report was left at the facility.

LPA Gutierrez reviewed facility progress notes for R1 which indicated between 5/22/22 to 6/222/22 R1 lost 10 lbs. Client Coordination Note Report dated 6/20/22, indicated staff reported R1, "does not eat his pureed diet." Physician was notified and requested a diet change. Physician's Fax Report dated 6/20/22, indicated current diet order was discontinued and Physician ordered "advance diet to mechanical soft diet and regular fluids. Finger foods ok to give as tolerated." LPA reviewed progress notes from May to June 2022, and all notes indicated staff continued to monitor resident. Interviews were conducted with six facility staff and five residents regarding allegation staff failed to provide care and supervision. Reporting Party (RP) stated staff spend time on their phone or socializing and will ignore residents. Six out of six staff denied staff is not providing care and supervision and denied observing staff spending time on their phone or ignoring residents. Four out of five residents interviewed reported no complaints regarding staff and reported they are assisted as needed. One out of five residents interviewed was unable to confirm or deny allegation. Initial 10-day inspection on 7/11/22 was conducted by LPA Sean Haddad. Per LPA Haddad, staff was responsive, tending to residents, and were not observed to be on their phones. During today’s inspection, LPA Gutierrez also did not observe any staff on their phones. Staff were observed engaging with residents in various activities, such as guided exercises, grooming, and setting up for lunch. Based on observations, conflicting information received during interviews conducted, and after a review of R1’s doctor’s orders, weight log, and facility progress notes, LPA is unable to determine if resident was not getting proper nutrition or if staff failed to provide care and supervision. Although the above 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 at this time the above allegations are unsubstantiated. An exit interview was conducted with WD and copy of this report was provided at the end of the inspection.

CONTINUED FROM LIC9099 Regarding the allegation that Staff did not provide resident's responsible party with complete paperwork at resident's admission to the facility , the following has been concluded: Based on a review of R1's records maintained at the facility and provided during the initial investigation visit, the resident and their authorized representative were provided with the following elements required by Title 22 regulations: R1's Pre-admission appraisal, Identification and Emergency contact form, signed and dated Admission agreement and all its required components including the facility's theft and loss policy. The Safeguard for Cash and Valuables form is also observed to be included in the records and is observed to be blank. Both the resident and their authorized representative declined to place any specific belongings into facility safeguarding. The resident's Individual Service Plan and updated physician report are also present. Based on the records reviewed and their corresponding dates and signatures, LPA was able to corroborate that facility staff has provided the resident and their authorized representative with all necessary items of documentation upon the resident's admission on or around August 21, 2022. As a result, the allegation is determined to be Unfounded, meaning that meaning the allegation is false, could not have happened and/or is without a reasonable basis. An exit interview was conducted and a copy of this report was provided to a facility representative. 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 CONTINUED FROM LIC9099 A follow-up visit was conducted on November 29, 2023. LPA was informed that the local law enforcement investigation was still ongoing and led an interview with facility administrator Anna Pastores. Additional witness interview attempted or conducted via telephone prior to the present visit. Regarding the allegation that Staff did not safeguard resident's personal property , the following has been concluded: Based on interviews conducted, site observation and records reviewed, it was confirmed that the facility meets all Title 22 requirements for its theft and loss policy. LPA also confirmed that the missing or stolen item reported as part of the present complaint was not placed under the facility's safeguarding responsibility. Law enforcement reporting was conducted appropriately by facility staff and is still pending at the time of the present visit. Additionally, the unit where R1 is observed to be residing is equipped with a lock to be used by the resident or their authorized representative at their own discretion. The evidence available at this time could not corroborate facility staff responsibility in misplacing or stealing the item reported missing or stolen. Therefore, the allegation is found to be Unsubstantiated, meaning that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove that the alleged violation occurred. Regarding the allegation that Resident sustained bruising while in care , the following has been concluded: Based on interviews conducted, a skin discoloration was observed on the R1's left hand by their authorized representative and facility staff multiple days after the reported incident involving a lost or stolen item. None of the interviews conducted were able to associate the discoloration with facility staff mishandling R1 or failing to provide adequate care and supervision. As a result, the allegation is found to be Unsubstantiated, meaning that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove that the alleged violation occurred. An exit interview was conducted and a copy of this report was provided to a facility representative.

This unannounced Case Management – Other inspection is being conducted by Licensing Program Analyst (LPA) Sean Haddad for the purpose of delivering an amended report for the Case Management – Incident inspection conducted on 08/24/23 and to conduct additional interviews to follow up on self-reported incident reports received in the Orange County Regional Office (OCRO) on 08/16/23 regarding an incident of rough handling resulting in injuries involving Staff #1 (S1), Resident #1 (R1) and Resident #2 (R2). LPA met with Administrator (AD) Anna Pastores and discussed the purpose of the inspection. During the inspection, LPA and AD reviewed and discussed the previously delivered report and the amended report and LPA delivered the amended report. During the inspection, LPA also conducted interviews and requested and reviewed resident records. LPA provided technical assistance regarding resident transfers and care plans. Based on the observations made during today’s inspection, no deficiencies are being cited per Title 22 Division 6 of the California Code of Regulations. An exit interview was conducted and copies of this report and the amended report were discussed with and provided to facility representative.

This unannounced Case Management – Incident inspection is being conducted by Licensing Program Analyst (LPA) Sean Haddad for the purpose of conducting additional interviews to follow up on self-reported incident reports received in the Orange County Regional Office (OCRO) on 08/16/23 regarding an incident of rough handling resulting in injuries involving Staff #1 (S1), Resident #1 (R1) and Resident #2 (R2). LPA met with Health Services Director (HSD) Alyson Caluza and discussed the purpose of the inspection. Administrator (AD) Anna Pastores arrived during the inspection. During today’s inspection, LPA and AD toured the facility. LPA conducted health and safety checks on R1 and R2, conducted interviews, and observed them to be in good health and observed no health and safety issues. LPA interviewed AD, 7 residents, and reviewed S1’s staff file. Based on the observations made during today’s inspection, no deficiencies are being cited per Title 22 Division 6 of the California Code of Regulations. An exit interview was conducted and a copy of this report was discussed with and provided to facility representative.