Oakmont of Pacific Beach.

[CONTINUED FROM LIC 9099] According to their LIC602 Physician’s Report, R1 was diagnosed with Alzheimer’s Dementia. Their doctor wrote that R1 was able to walk without any motor impairment or assistive device, but due to their cognitive impairment, R1 was not safe to leave the facility unassisted. Interviews of staff and outside sources unanimously showed that R1 resided in the Assisted Living (AL) section of the facility, where there were neither secured perimeter nor delayed-egress doors present. During the allegation period, Licensee employed a Phillips Roam Alert system at the facility, which helped staff monitor residents in AL who were diagnosed with dementia. The system worked by having selected residents wear a Roam Alert Bracelet device. When such residents came near the thresholds of perimeter door exits, the system would trigger an audible localized alarm at that door and send a wireless signal to the pager devices which the caregivers carried, prompting staff to then redirect the resident away from the door. The system did not physically prevent residents from exiting (such doors remained unlocked from the inside). Licensee’s Phillips Roam Alert system was consistent with CCR 87705, titled Care of Persons with Dementia, which requires Licensees to install “an auditory device or other staff alert feature to monitor exits on exterior doors” that are accessible to residents who “who may be at risk for elopement.” The facility’s written Plan of Operation (on file with CCLD) and Admissions Agreement contract both reiterated that the Roam Alert Bracelet was a safety requirement for any resident diagnosed with dementia living in the facility’s AL section. Licensee’s written Individual Service Plan (i.e., Care Plan) for R1 reiterated that R1 had dementia, was not safe to leave the facility unassisted, and needed to continuously wear their Phillips “Roam Alert Bracelet” for their personal safety. Per manager interviews, Licensee required its caregivers to respond to Roam Alert alarms as quickly as possible, but not longer than five (5) minutes. Staff interviews, corroborated by R1’s Admissions Agreement and an E-mail from a senior manager, also showed that that facility’s exterior exit doors (including the lobby’s front door) were required to be physically locked from the outside at nighttime, for resident safety. The Complainant claimed that on a day in March 2021, they personally observed that R1’s Roam Alert Bracelet wrist strap had been cut, and the device was sitting atop R1’s bedside table; R1 allegedly told them that they had not worn the bracelet “for a while.” Interviews of two facility managers [Staff #1 (S1) and Staff #2 (S2)] showed that at some point during the allegation period, R1’s Roam Alert Bracelet indeed had been cut off/removed, and that S2 subsequently reattached the device to R1. The totality of interviews did not clearly establish how long the Roam Alert Bracelet had been detached from R1 before discovery/correction (making it difficult to evaluate Licensee fault/culpability). [CONTINUED ON LIC 9099-C, 2 of 2] 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 LIC 812-C, 1 of 2] The Complainant claimed that on a day in March 2021, and again on a day in May 2021, the facility’s front door was not locked form the outside at nighttime, as required. They also claimed that during the May 2021 date, R1’s Roam Alert Bracelet triggered the lobby front door audible alarm, but it took over twenty-five (25) minutes for the first facility staff to respond to it. CCLD subsequently obtained video recording, which was filmed around 9:30 PM on 05/02/2021. The video showed: a) The facility’s front door was unlocked during this night, allowing any person to enter from the outside without staff awareness/involvement; and, b) A loud audible alarm continuously sounded at the lobby front door, which facility staff did not respond to during 13-minute video. The person who filmed the video told CCLD that the video ended there because there was no more storage space on their smart phone camera, but that it actually took staff nearly twice as long to respond to this alarm. Based on records and interviews, a preponderance of evidence exists to show that facility staff did not meet the safety needs of a resident diagnosed with dementia. The allegation is therefore Substantiated, and one (1) deficiency was cited for it per California Code of Regulations, Title 22 (refer to the attached LIC 9099-D page). A Plans of Correction was jointly developed with the Licensee. An exit interview was conducted with Health Services Director Keisha Bean, to whom a copy of this report, the LIC 9099-D page, and the Licensee/Appeal Rights (LIC9058 03/22) were provided. 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 LIC 9099-A] All chips were also physically carried through multiple exterior exit doors thresholds (to include the lobby front door), for a total of three (3) passes per door. The chips consistently triggered a loudly audible alarm at the door annunciator itself and sent signals to multiple pager devices which the caregivers carried. Both types of alerts continued to be active until staff silenced them by entering a manual key code at the triggering door. This battery of tests, corroborated by interviews of facility managers and frontline caregivers, showed the facility’s egress alert system was reliably working, from a technical/hardware standpoint. Based on records and interviews, a preponderance of evidence does not exist to show that the facility’s egress alert system was unreliable. The allegation is therefore Unsubstantiated, and no deficiency was cited for it. An exit interview was conducted with Health Services Director Keisha Bean, to whom a copy of this report and the Licensee/Appeal Rights (LIC9058 03/22) were provided.

Licensing Program Analyst (LPA) Iby Strong conducted an unannounced Required Annual Inspection. The facility file was reviewed prior to the visit. LPA was welcomed by, identified herself to, and discussed the purpose of the visit with Executive Director Emily Turner. According to the facility’s license, the facility has a maximum capacity of 92 residents, of whom all may be non-ambulatory and 8 may be bedridden with a hospice waiver for 8. LPA toured the interior and exterior of the facility and inspected multiple rooms. The facility was sanitary, and in good repair. Pathways were free of obstruction and slip hazards. Resident bedrooms contained the required furnishings. Doors, windows, toilets, and showers were in working order. The facility had sufficient space and equipment to facilitate dining, laundry, visitation, meetings, and resident activities. Cooking/dining equipment and utensils were present. LPA toured the commercial kitchen. There was enough dry food for two weeks and enough perishable food for two or more days. LPA also observed the emergency food supplies properly stored. There were no toxic chemicals/poisons accessible to residents. Medications were labeled, as required, and stored in locked areas. Medication administration record was complete. Water temperature was measured at 106.8 degrees F in assisted living and 107 degrees F in memory care. No pool or body of water present. Per Executive Director, no firearms or ammunition are kept at the facility. Facility has an internal fire system. First aid kits were complete and readily accessible. Resident records reviewed had required documentation. Staff records reviewed contained required documentation. No deficiencies were cited on todays visit. An exit interview was conducted with Executive Director, to whom a copy of this report and the Licensee/Appeal Rights (LIC9058 03/22) were provided during the visit.

On 06/14/25, staff went to the resident’s room to dispense medications, the resident was lying in bed. The staff observed smears on the bedroom wall and inquired with the residents. The residents reported they had bugs in their apartment and had smashed them the night prior. The staff immediately reported the issue to management. The Maintenance Director inspected the room and contacted their contracted pest control company to inspect. The Pest control company came on the same day, 06/14/25 to inspect, and confirmed there were bed bugs. The Maintenance Director explained as soon as they were made aware, the residents’ bodies were checked for bites, residents were showered, relocated, clothes washed, items disposed, and inspected by pest control. They also had a dog groomer come in to treat the resident couple’s dog to ensure safety. As of 06/16/25 the apartment had one full chemical treatment completed by the pest control company. The Executive Director reported the bed bug treatment was completed, no visible sign of bed bugs post treatment, follow up treatment to be completed out of precaution, and the neighboring rooms inspected with no signs of bed bugs in any other area. It was discovered the contracted company was unable to treat with heat, which was needed. Therefore, the facility contacted another pest control company that was able to assist. LPA spoke with a representative of the newly obtained pest control company that verified the resident couple’s apartment had a bed bug infestation but was being treated. The representative also stated they felt the issue would be resolved and confirmed this was a new bed bug infestation. The representative also stated the facility was following necessary precautions. The facility’s housekeeper was assigned to change the linens once a week. The housekeeper did not report any bed bugs or signs of bed bugs. Staff that are assigned to wash the residents’ clothing did not observe any bugs on the residents’ clothing. It is unknown when the bed bug infestation began. The Executive Director confirmed 06/14/25 was the first observation of bed bugs and prior to that it was not reported by staff, residents, or the private companions. The facility acted appropriately to rid the facility of pests/bed bugs by contacting the contracted pest control company and relocating the residents. When it was discovered, the contracted company could not treat with heat, the facility hired another pest control company, relocated the residents and followed guidelines for bed bug infestation. During the course of the investigation, interviews were conducted, and records were reviewed. Investigation revealed inconsistent statements and information obtained did not present a preponderance of evidence to support or corroborate the allegation. The allegation was deemed unsubstantiated. An exit interview was conducted and a copy of this report along with Licensee Rights (LIC 9058 03/22) were provided to Executive Director, Emily Turner whose signature below confirms receipt of these rights. 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 This agency has investigated the complaint, alleging staff did not ensure reporting requirements were followed. We have found that the complaint was unfounded, meaning that the allegation was false, could not have happened and/or is without a reasonable basis. An exit interview was conducted and a copy of this report along with Licensee Rights (LIC 9058 03/22) were provided to Executive Director, Emily Turner whose signature below confirms receipt of these rights. LPA was absent from the facility from 12:45pm-1:45pm.

Licensing Program Analyst (LPA) Juliana Barfield conducted an unannounced Case Management - Incident visit. LPA was welcomed by, identified herself to and discussed the purpose of the visit with Executive Director Caroline Senteno. Today's visit was in response to licensee’s self-reported death of Resident #1 (R1), received at the CCLD San Diego Regional Office on 08/23/2024. [See LIC 811 Confidential Names List for a description of (R1]. Per the report, (R1) passed away on 08/14/2024. During today’s visit, LPA performed a brief facility tour and welfare check on remaining clients, finding no safety concerns. LPA also collected copies of and reviewed pertinent records, and interviewed relevant staff. No deficiencies were observed or cited during today’s visit. An exit interview was conducted with Caroline Senteno, to whom a copy of this report, the LIC811 Confidential Names List, and the Licensee/Appeal Rights (LIC9058 03/22) were provided during the visit.

Licensing Program Analyst (LPA) Ramon Serrano conducted an unannounced Required Annual Inspection. The facility file was reviewed prior to the visit. LPA was allowed entry and discussed the purpose of the visit with Executive Director Caroline Senteno. According to the facility’s license, the facility has a maximum capacity of ninety two (92) residents. All of whom may be non-ambulatory. Hospice waiver approved for eight (8) residents. Eight (8) residents may be bedridden. LPA, accompanied by Executive Director toured the interior and exterior of the facility, and inspected five rooms on all three floors. The facility was clean, sanitary, and in good repair. Pathways were free of obstruction and slip hazards. Resident bedrooms contained the required furnishings. Doors, windows, toilets, and showers were in working order. Extra linens and hygiene supplies were present, as well as Personal Protective Equipment. Hot water temperature was measured in the facility at 116 degrees F. The ambient temperature inside the facility was measured at 72 degrees F. The facility had sufficient space and equipment to facilitate dining, laundry, visitation, meetings, and resident activities. There was at least 2 days of perishable food, and at least 7 days non-perishable food present, all safely stored. Cooking/dining equipment and utensils were present. There were no toxic chemicals/poisons accessible to clients. Medications were labeled, as required, and stored in locked areas. Their are no bodies of water on the premises. Per Executive Director, no firearms or ammunition are kept at the facility. Carbon monoxide detectors, emergency lighting, and facility telephone were all working. Fire extinguisher(s) were present. First aid kit(s) were complete and readily accessible. Required licensing postings were observed in visible areas of the facility. [CONTINUED ON LIC 809-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 LPA reviewed multiple staff and resident records/files. LPA interviews did not raise any licensing concerns. The files which LPA reviewed contained required documents. Confidential records were stored in locked areas. No deficiencies were observed or cited during today's annual inspection. An exit interview was conducted with Caroline Senteno whom a copy of this report and the Licensee/Appeal Rights (LIC9058 03/22) were provided during the visit.

Licensing Program Analyst (LPA), Natasha Persaud conducted a Case Management - Incident visit. LPA met with Executive Director, Caroline Senteno and discussed the purpose of the visit. Community Care Licensing received a self reported incident involving the death of Resident #1 (R1). The Death Report stated on 04/07/24, R1 was found in their bed by staff. R1 had signs of illness and was found with an opened bottle of body wash in their room. R1's Physician' Report dated 07/13/23 indicated R1 had a diagnosis of a Major Neurocognitive Disorder and was allowed direct access to personal grooming and hygiene items without risk. The facility contacted 911 and R1 was transported to the hospital. R1 passed away at the hospital on 04/07/24. Today, LPA requested records and conducted interviews with staff. No deficiencies were cited during today's visit. An exit interview was conducted and a copy of this report along with Licensee Rights (LIC 9058 03/22) were provided to Executive Director, Caroline Senteno whose signature below confirms receipt of these rights.

Licensing Program Analyst (LPA's) Amy Rodgers and Julianna Barfield conducted an unannounced Case Management - Incident visit. LPA's was welcomed by, identified themselves to, and discussed the purpose of the visit with Executive Director Caroline Senteno. LPA then met with Health Service Director Freida Long. Today's visit was to conduct a CCLD visit, which occurred on 2/5/2024. Visit was in response to licensee’s self-reported death of Resident #1 (R1), received at the CCLD San Diego Regional Office on 2/6/2024. [See LIC 811 Confidential Names List for a description of R1]. Per the report, R1 passed away on 2/5/2024. During today’s visit, LPA's performed a brief facility tour and welfare check on remaining residents, finding no safety concerns. LPA also collected copies of additional pertinent care records and interviewed additional staff. No deficiencies were cited during today's visit. An exit interview was conducted with Health Service Director Long, to whom a copy of this report, the LIC811 Confidential Names List, and the Licensee/Appeal Rights (LIC9058 03/22) were provided during the visit.

Licensing Program Analyst (LPA) Dang Nguyen conducted an unannounced subsequent Case Management - Incident visit. LPA was welcomed by, identified himself to, and discussed the purpose of the visit with Executive Director Caroline Senteno. LPA then met with Assisted Living Coordinator Norma Munoz. Today's visit was follow-up to CCLD’s first visit, which occurred on 10/06/2023. Both visits were in response to licensee’s self-reported death of Resident #1 (R1), received at the CCLD San Diego Regional Office on 10/05/2023. [See LIC 811 Confidential Names List for a description of R1]. Per the report, R1 passed away on 09/25/2023. During today’s visit, LPA performed a brief facility tour and welfare check on remaining residents, finding no safety concerns. LPA also collected copies of additional pertinent care records and interviewed additional staff. No deficiencies were cited during today's visit. An exit interview was conducted with Munoz, to whom a copy of this report, the LIC811 Confidential Names List, and the Licensee/Appeal Rights (LIC9058 03/22) were provided during the visit.

Licensing Program Analyst (LPA) Daniel Pena conducted a case management visit to investigative the circumstances surrounding a Death Report received on January 16, 2024. LPA met with Executive Director Caroline Senteno and discussed the purpose of the visit. LPA reviewed R1's facility file, requested relevant records, and conducted interviews. The Death Certificate was also requested during the visit. No deficiencies were issued during the visit. An exit interview was conducted with Executive Director Senteno and a copy of this report and Licensee Rights (LIC9058 01/2016) were provided at the conclusion of the visit.

Licensing Program Analyst (LPA) Dang Nguyen conducted an unannounced Case Management - Incident visit. LPA was welcomed by, identified himself to, and discussed the purpose of the visit with Executive Director Caroline Senteno. Today's visit was in response to licensee’s self-reported death of Client #1 (C1), received at the CCLD San Diego Regional Office. [See LIC 811 Confidential Names List for a description of C1]. Per the report, C1 passed away on 09/25/2023. During today’s visit, LPA performed a brief facility tour and welfare check on remaining clients, finding no safety concerns. LPA also reviewed and collected copies of pertinent records, and interviewed relevant staff. No deficiencies were cited during today's visit. An exit interview was conducted with Senteno, to whom a copy of this report, the LIC811 Confidential Names List, and the Licensee/Appeal Rights (LIC9058 03/22) were provided during the visit.

Licensing Program Analyst (LPA) Rebecca Ruiz conducted an unannounced case management visit. LPA was greeted by, identified herself to, and explained the purpose of her visit to Executive Director Caroline Senteno. This visit was initiated due to a SOC341 that was self reported by the Licensee to the Department on 8/10/2023. The SOC341 narrative described an incident between Resident 1 (R1) and an unidentified individual. During today’s visit, LPA toured the facility, conducted a health and safety check, observed residents in care, and reviewed and obtained copies of facility records. No immediate health or safety concerns were observed during the facility tour. At this time, the incident required further investigation and additional follow-up visits may be necessary. No deficiencies were cited during today’s visit. An exit interview was conducted with Executive Director Caroline Senteno, whose signature below confirms receipt of a copy of this report and the Licensee Appeal Rights (LIC9058 01/16).

Licensing Program Analyst (LPA) Dang Nguyen conducted an unannounced Case Management - Incident visit. LPA was welcomed by, identified himself to, and discussed the purpose of the visit with Executive Director Caroline Senteno. Today's visit was in response to an LIC624 Incident Report, which licensee self-submitted to the CCLD San Diego Regional Office (received on 08/03/2023). According to the LIC624: during the evening of 08/01/2023, Resident #1 (R1) eloped from the facility (left without staff supervision). [See LIC 811 Confidential Names List for a description of C1.] R1 was returned to the facility unharmed, later that same evening. During today’s visit, LPA performed a facility tour and welfare check, verifying that R1 was unharmed. LPA tested facility's delayed-egress exit doors, finding that they were operational and complaint with regulation. LPA also collected pertinent care and administrative records, and interviewed R1 and relevant staff. At the present time, the incident requires further investigation. Possible follow-up telephone calls and/or visits are necessary. No deficiencies were observed or cited during today's visit. An exit interview was conducted with Senteno, to whom a copy of this report, the LIC811 Confidential Names List, and the Licensee/Appeal Rights (LIC9058 03/22) were provided.