Oakmont of Whittier.

The investigation revealed the following: Allegation: Staff stole resident's funds. It is alleged that R1’s bank card was stolen and it is believed that S3 may have stolen the card to make multiple purchases. LPA contacted local police department, spoke to the detective and obtained a copy of the police report, the police report and detective disclosed that there was not enough proof/evidence to link the charges made to R1’s card to any staff at the facility and the allegation was unsubstantiated. LPA interviewed 6 staff and each denied the allegation stating that they have never stolen any items or money from the residents nor have they ever witnessed another staff steal from the residents. S3 stated they have never stolen any money from residents and that this particular day in question S3 observed R1’s roommate with a wallet at their desk, the wallet belonged to R1 and it was confiscated, returned to R1 and reported to management immediately. LPA interviewed 6 residents and each denied the allegation, interview with R5 revealed that they had money missing upon moving in but did not believe staff had anything to do with it, staff encouraged R5 to file a police report and although the money was never found R5 stated that they believe they must have dropped it or misplaced it as this is something they do at times. R5 stated this is the only time this has ever happened. Based on statements and interviews conducted with staff/residents, review of police report and facility file records, there was not enough supportive evidence to concur with the reported allegation. 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 held, and a copy of this report was provided.

The investigation revealed the following: regarding the allegation “Staff did not prevent a resident from being sexually abused while in care.” It is alleged staff did not prevent R1 from being sexually abused while in care. Interviews conducted by Community Care Licensing Investigation Branch did not corroborate this allegation. Eight (8) out of the eight (8) staff interviewed by LPA Ramirez, did not corroborate with this allegation. Staff interviews revealed R1 suffered from cognitive impairment and aggressive behaviors. Interview with S6 revealed prior to R1 relocating to the facility memory care unit, R1 revealed to S6 that they (R1) experienced a traumatic event when they were younger and S6 believed this traumatic event was re-manifested into R1’s memory and that’s why R1 made this allegation. S6 revealed they did not care for R1 once R1 moved to the facility memory care but, S6 would still go visit R1 and observed R1 to be well cared for by memory care staff. Four (4) out of the four (4) residents interviewed by LPA Ramirez did not corroborate this allegation. Despite several attempts to contact R1 by Community Care Licensing Investigation Branch and LPA Ramirez, all attempts were unsuccessful. 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 . “Staff did not safeguard resident's personal belongings.” It is alleged staff did not safeguard R1’s hearing aid devices and walker. Eight (8) out of the eight (8) staff interviewed by LPA Ramirez, did not corroborate with this allegation. S8 revealed that R1’s hearing aids were charged in the memory care medication room; along with all other memory care residents’ hearing aids. S8 revealed they recalled R1’s hearing aids were believed to have been misplaced but were located shortly after in the medication room. S7 revealed that R1’s hearing aids were placed on R1 during the day and charged at night in the memory care medication room. S7 revealed that R1 would take off their hearing aids often and staff would place them on the charger. S7 revealed they were never told by any staff or by R1’s family that R1’s walker was missing. Review of R1’s Client/Resident Personal Property and Valuables (LIC 921), did not corroborate this allegation. LPA Ramirez made multiple attempts to contact R1 and R1’s responsible party but all attempts were unsuccessful. Four (4) out of the four (4) residents interviewed by LPA Ramirez did not corroborate this allegation. R2 revealed that they have never had any personal belongings missing. R3 revealed staff treated them well and they felt safe to leave expensive personal belongings out when staff clean their room. 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 . No deficiencies were cited during this complaint investigation. A copy of this report was provided.

Licensing Program Analyst (LPA) Kimberly Ramirez conducted an unannounced subsequent annual inspection visit on 10/18/2025 and was greeted by Gina Alvarez- Business Office Director and discussed the purpose of today’s visit. LPA Ramirez conducted initial annual inspection on 10/02/2025. Administrator Adriane Runge arrived shortly after to assist. LPA Ramirez identified herself and explained the purpose of the visit. Operational Requirements: The fire clearance is approved for ninety-seven (97) non- ambulatory resident, of which seven (7) may be bedridden. This facility may retain no more than fifteen (15) hospice residents. There were eight (8) residents under hospice care, during annual inspection. Staffing: Administrator Certificate (7003384740) for Adriane Runge with an expiration date of 06/05/2027 was observed. Staff employed are over the age of 18 and are fingerprint cleared and associated to the facility. Personnel Records Training: Staff files are maintained at the facility. LPA Ramirez observed required annual training, CPR and First Aid for six (6) out of the six (6) personnel record reviewed. LPA Ramirez observed TB testing results, Health screening, fingerprint clearance and job application for six (6) out of the six (6) personnel record reviewed. Resident Records/Incident Reports: LPA reviewed resident records for six (6) residents in care. Resident records are maintained at the facility. Admission Agreement, Physician's Report (including T.B and Ambulatory Status), Consent for Medical Treatment, Preplacement Appraisal Information, Resident Pre-Appraisal, Care Plan/Appraisal/Needs and Services Plan, Resident Rights were observed. Planned Activities: LPA Ramirez observed board games, magazines, and other activities for residents. Disaster Preparedness: The facility has the Emergency Disaster Plan (LIC610D/9 pages) in place. Last documented emergency drills were conducted on 09/27/2025. LPA Ramirez observed facility sketches with exits and emergency exits routes throughout various locations of the facility. LPA Ramirez observed emergency food supply located in pantry. Health Related Services/Incidental Medical Services: The medications are centrally stored in the medication room and in bubble packs and/or original containers. LPA Ramirez observed Centrally Stored Medication and Destruction Record. The facility provides incidental medical services. No deficiencies were observed during this visit. Exit interview conducted. A copy of this report was provided.

Licensing Program Analyst’s (LPA) Kimberly Ramirez conducted an annual inspection on 07/08/2025. LPA met with Gina Alvarez- Business Office Director and discussed the purpose of today’s visit. Administrator Adriane Runge arrived shortly after to assist with tour. This facility is licensed to serve ninety-seven (97) non- ambulatory resident, of which seven (7) may be bedridden. This facility may retain no more than fifteen (15) hospice residents. There were eight (8) residents under hospice care, during annual inspection. LPA utilized the Compliance and Regulatory Enforcement (CARE) tools for the visit today and observed the following: See 809-C for continued 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 Physical Plant and Environment safety: Disinfectants, cleaning solutions, poisons and other items that could pose a danger if readily available to residents, were observed to be inaccessible to residents. LPA observed carbon monoxide detectors and smoke alarms in hallways. Smoke alarms and carbon monoxide detectors were tested and observed to be operational. LPA inspected six (6) rooms; of which three (3) were located in memory care. All resident bedrooms contained the required furniture, linens and lighting. Water temperatures in all grooming and bathing areas were measured to be with 105 – 120 degrees F. Facility maintains a weekly waterlog to record water temperature throughout the facility. LPA Ramirez observed postings encouraging proper hand washing etiquette in restrooms. LPA Ramirez observed grab bars near toilets and inside showers. LPA observed evacuation chairs in stairways. Food Service: LPA observed sufficient supply of nonperishable for one week and perishable foods for a minimum of two days in the facility kitchen area. Soaps, detergents, and cleaning compounds were observed to be stored away from food supplies. Freezers and refrigerators were observed to be clean and within temperatures of 0 degree F (-17.7 degree C), and refrigerators with a maximum temperature of 40-degree F. (4 degree C). LPA observed facility weekly and daily menu, which is approved by the facility certified dietary manager. LPA observed kitchen staff preparing for lunch while wearing hair nets and gloves. LPA observed several dining room servers disinfecting tables and counters while wearing gloves and hair nets. Planned Activities: LPA observed a calendar for October of 2025 with various activities and outings for residents. LPA observed sufficient outdoor space in both assisted living section and in memory care. Residents Rights-Information: LPA observed the following postings in common areas throughout the facility: Complaint Poster (PUB 475), personal rights, and nondiscrimination notice. LPA Ramirez observed facility computers with internet access and a facility land line. Residents with Special Needs: LPA observed signs posted indicating “No smoking - Oxygen in Use” in various locations of the facility. LPA observed several oxygen tanks in resident rooms secured in stands. Knives, sharps or other items that could pose a danger to residents with dementia, were observed to be inaccessible. Auditory devices and delay egress perimeters were observed to be in working order. Due to time constraints, LPA Ramirez will return at a later time to complete record review and interviews; required for annual inspection. No deficiencies were cited at this time. The Exit interview was conducted with Administrator Adriane Runge. A copy of this report was provided.

Allegation: Staff did not ensure centrally stored medication was locked and inaccessible to residents. It has been alleged that staff misplace residents’ medication which would later be found inside the residents’ rooms. Staff interviews revealed that residents medications are locked inside a medication cart which is stored inside the locked medication room. Interviewed staff indicated that residents’ medications are not misplaced nor later found in residents’ rooms. Interviewed staff indicated that they have not received any complaints/concerns pertaining to this matter. Resident interviews revealed that staff provide residents with their medication daily and in a timely manner. Interviewed residents indicated that staff provide supervision when medication is provided to ensure the medication is consumed by the resident. Interviewed residents indicated that they do not have direct access to medication as the medication is centrally stored inside a medication cart and is inaccessible to residents. Interviews do not corroborate this allegation. Allegation: Staff falsified medication records. It has been alleged that staff misplaced a R-1’s Oxycodone pill and rather than reporting the pill missing, staff allegedly “falsely reporting it as a miscount”. Staff interviews revealed that on 04/26/25, R-1's Oxycodone pill #16 was discovered inside the medication cart and not inside the bubble pack. Interviewed staff indicated that the foil of R-1's bubble pack for Oxycodone somehow was broken/punctured under pill #16 which caused it to fall out of the medication bubble pack and onto the medication cart. Staff interviews revealed that R-1’s Oxycodone pill #16 medication was not missing as it was found inside the medication cart, therefore, per staff interviews, this medication was not reported as a “miscount”. Interviewed staff indicated that controlled medications are counted by staff on a daily basis and are logged on the controlled medication shift count. Interviewed staff indicated that R-1 takes this medication on an as needed basis and the last administration was on 03/16/25. Interviewed staff indicated that they have not received any complaints/concerns pertaining to this matter. Interviews and reviewed documentation do not corroborate this allegation. Refer to LIC 9099C for the continuation of this report. 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 Allegation: Staff did not provide adequate supervision resulting in resident missing their medication dosage. It has been alleged that staff dispensed a diabetic medication to a resident (R-2) but did not ensure that the resident (R-2) consumed it and left the room. Staff interviews revealed that staff provide adequate supervision when administering residents’ medication. Interviewed staff indicated that R-2 takes their medication in front of the medication technician. Interviewed staff indicated that they have not found any unconsumed medication inside R-2’s room. Interviewed staff indicated that they have not received any complaints/concerns pertaining to this matter. Resident interviews revealed that staff administrating medication provide supervision to residents during the medication distribution to ensure residents are consuming their medication. Interviewed residents indicated that staff do not just provide them with their medication and leave. Interviewed residents indicated that they do not have any concerns pertaining to this matter. Interviews do not corroborate this allegation. Allegation: Staff left residents in soiled diapers for extended periods of time It has been alleged that staff avoided changing residents’ briefs at the end of their shift and that residents were wet, soiled and waited an additional hour and a half to be changed. Staff interviews revealed that staff do not leave residents in soiled diapers for extended periods of time. Interviewed staff indicated that they conduct rounds every (2) hours and as needed to change residents with soiled diapers. Interviewed staff indicated that they do not wait until the end of their shift to change residents’ diapers nor wait an hour and a half to change residents' diapers. Interviewed staff indicated that they have not received any complaints/concerns pertaining to this matter. Resident interviews revealed that staff provide incontinence care in a timely manner. Interviewed residents indicated that staff do not leave them in soiled diapers for an extended period of time. Interviewed residents indicated that they do not have any concerns pertaining to this matter. Interviews do not corroborate this allegation. 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 and a copy of this report and appeal rights were provided to Adriane Runge (Executive Director).

It is alleged staff gave R1 doses of medication without doctor’s consent. Interviews conducted with residents revealed 4 out of 7 residents stated their medication is provided as prescribed and 3 out of 7 residents were not able to provide information due to cognitive skills. Interviews with staff revealed medication technicians provide medication as prescribed by the physician. Documents review revealed, on 3/11/25 a medication clarification sheet was signed by nurse practitioner listing two orders of quetiapine, one for 25mg and another for 50mg. Medication administration record notes the same medications listed on medication clarification. Charting notes revealed, on 5/12/25 and 5/13/25 R1’s responsible party shared concerns about the medication dosage to medication technician. On 5/13/25 facility staff contacted nurse practitioner to address R1’s responsible party concerns. On 5/14/25 facility staff received new order of medication per R1’s responsible party request. Medication review did not reveal medication errors. Although the allegation may have happened the facility staff were providing medication as prescribed. Facility noted R1’s responsible party concern and address it with physician. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is UNSUBSTANTIATED. Regarding allegations: Facility staff handled residents in a rough manner and Facility staff yelled at resident. It is alleged staff aggressively sat a resident down and yelled at another resident. Interviews conducted with residents revealed 7 out of 7 residents stated that facility staff treat them well and respectfully. Interviews with staff revealed staff have not observed any other staff treat the residents in an aggressive manner or yelling at residents. Per administrator there have not been any incidents of staff treating residents disrespectfully report it. Training on Communication; Courtesy was provided to staff #2 on 4/22/25. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is UNSUBSTANTIATED . Regarding allegation: Facility staff did not observe proper food service sanitation practices. It is alleged staff serve food with dirty hands and without gloves. Interviews with residents revealed 4 out of 7 residents stated staff take measurements to observe sanitation practices and 3 out of 7 residents were unable to answer due to cognitive skills. Interviews with staff revealed staff use gloves and hairnets to serve the food provided to the residents and practice hygiene while providing care. (CONTINUED ON LIC 9099C) 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 Interviews with staff revealed staff use gloves and hairnets to serve the food provided to the residents and practice hygiene while providing care. Training on basic hand hygiene was provided on 6/10/24 and About Infection Control and Prevention on 6/8/24 was provided to staff #2. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is UNSUBSTANTIATED. Regarding allegation: Facility staff did not safeguard resident’s personal belongings . It is alleged R1’s clothes have gone missing. Interviews conducted with residents revealed 3 out of 7 residents stated to take care of their personal care themselves. However, personal items have not gone missing. 1 out of 7 residents stated none of their personal belongings have gone missing. 3 out of 7 residents were unable to answer due to cognitive skills. Document review revealed R1’s personal property and valuables dated: 3/8/24 list clothing in general. However, there is not a specific number of items. During facility’s tour LPA observed R1’s room and observed R1’s clothing folded in one closet and personal belongings on another closet. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is UNSUBSTANTIATED . Exit interview was conducted with Adriane Rugen Administrator and a copy of this report was provided.

Licensing Program Analysts (LPA) Elizabeth Irra conducted an annual inspection visit. LPA met with Adriane Runge and discussed the purpose of today’s visit. LPA utilized the Compliance and Regulatory Enforcement (CARE) tools for the visit today and observed the following: Infection Control: Facility has an Infection Control Policy (binder) in place. Operational Requirements: Facility is adhering to the operational requirements. This facility is approved for (97) non-ambulatory residents (7 of which may be bedridden and 15 of which may be under hospice). There are currently (47) residents in the assisted living facility and (25) memory care residents. Physical Plant & Environment Safety: LPA toured facility grounds. Fire smoke alarms and carbon monoxide detectors observed. The fire extinguishers are located throughout the facility and appear to be full (last service date 03/27/24). Signal system tested and operable. Last emergency drill was conducted on 08/29/24. Emergency evacuation chairs were observed at the stairways. Hot water temperature measured within regulations. The hot water supply measured at the following temperatures: 106.5* to 110.0*. Bathrooms have non-skid surfaces and grab bars. Staffing : Facility is adhering to staffing requirements. Refer to LIC 809C for the continuation of this report. 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 Personnel Records-Training : Staff files are maintained at the facility. LPA reviewed staff files for S-1 through Staff #5 (S-5). Staff have current First Aid/CPR certification. Staff have their Health Screening and Tuberculosis Screening on file. Staff are also trained on Abuse Reporting and Resident Rights. Resident Rights-Information: Resident rights are posted and included in Resident files. Planned Activities: This facility has an activity room and provides a variety of activities for the residents. Activity schedule is posted. Food Service: There are sufficient food supplies of 2-day perishable and (1) week of non-perishable items. The food is properly stored in the refrigerator. Posted menu observed. Pesticides and cleaning supplies are kept away from the food preparation areas. Kitchen is kept clean and free from rodents and other vermin. Plates, cups and utensils are kept cleaned and stored properly. Dining areas have adequate seating in both the assisted living and memory care dining rooms. Resident Records-Incident Reports: LPA reviewed Resident files for Resident #1 (R-1) through Resident #7 (R-7). Resident files are maintained at the facility. Resident files have the required documents. Admission Agreement, Physician's Report (including T.B and Ambulatory Status), Consent For Medical Treatment, Preplacement Appraisal Information, Resident Pre-Appraisal, Assessment Summary, Resident Rights were observed. Disaster Preparedness: The facility has a Disaster Preparedness manual (binder) in place. Health Related Services/Incidental Medical Services: The medications are stored and locked (medication carts) inside the medication room. Exit interview conducted, copy of appeal rights and a copy of this report was provided to Adriane Runge.

Residents interviewed were unable to corroborate the allegation. Residents interviewed stated that staff are attentive, and check on them often. Residents stated that if a resident fall, staff will assess them immediately. Although resident #1 experienced two falls, on 4/1/24 and 4/2/24, the standard of proof has not been met because the preponderance of the evidence does not demonstrate the facility was in violation of Title 22 regulations. Regarding the allegation that : Staff left a resident on the floor for an extended period of time after falling. The investigation revealed that resident #1 experienced a fall on 4/1/24, and on 4/2/24. Resident #1 was sent to the hospital, and was hospitalized from 4/2/24 -4/7/24. Review of hospital documents indicate that resident #1 sustained minor injuries due to fall(s). Administrator and staff interviewed denied the allegation. They stated that residents are checked on every two hours, or more frequently according to their care needs. Staff stated that when resident #1 fell, he was found by staff, assessed, and sent to the hospital. Staff stated that resident #1 was not left on the floor for an extended period of time. Residents interviewed were unable to corroborate the allegation. Residents interviewed stated that staff are attentive, and check on them often. sw3 Although the allegations may have happened or are valid, there is not preponderance of evidence to prove the alleged violations did or did not occur, therefore, the allegations are UNSUBSTANTIATED. Exit interview was conducted and a copy this report was provided.

Regarding the allegation that : Facility does not provide a safe environment for resident. The investigation consisted of interview(s) with Administrator, Staff #1 - Staff #4, and Resident #1 - Resident #5. Administrator and staff interviewed stated that the facility does provide a safe environment for resident(s). Staff interviewed stated that resident(s) are assessed upon admission and are regularly observed for changes in condition. Residents interviewed were unable to corroborate the allegation. Five out of five residents interviewed stated that the facility does provide them with a safe environment. Regarding the allegation that : Facility staff are not adequately providing resident assistance and supervision while in care. Administrator and staff interviewed stated that staff are providing adequate assistance and supervision. Staff interviewed stated that they check on residents frequently, and they assist residents according to the resident(s) care plan. Residents interviewed were unable to corroborate the allegation. Five out of five residents interviewed stated that staff are providing them with assistance and supervision. Regarding the allegation that : Facility staff are not ensuring that resident is adequately fed while in care, and facility staff are not ensuring that resident is adequately hydrated while in care. Administrator and staff interviewed, stated that the staff do ensure that resident(s) are adequately fed and hydrated while in care. They said that the facility provides a sufficient amount of food and beverages to resident(s) and they assist resident(s) with eating and drinking, if they need assistance. Residents interviewed were unable to corroborate the allegation. Five out of five residents interviewed stated that staff do ensure that they are receiving enough food and hydration at the facility. Regarding the allegation that : Resident's sensor alert device was not working properly. Administrator and staff interviewed stated that the sensor alert devices are in resident room(s) in memory care. Staff interviewed stated that the sensors detect motion, and alert the staff if a resident falls, or is moving around in the room. Staff interviewed stated that the devices are working properly. Residents interviewed were unable to corroborate the allegation. Five out of five residents interviewed stated that that the sensor alert devices are working properly. LPA observed that the sensor alert devices are working properly. 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, and a copy of the report was provided.

Licensing Program Analyst (LPA) Angelica Rea conducted an unannounced annual visit using the Inspection Tool. LPA met with Executive Director Janette Hill and explained the reason for the visit. Physical Plant was toured, medications, staff and resident files, were reviewed, food supply was inspected, and a sample of staff and residents were interviewed. LPA Rea and Ms. Hill toured the facility including common areas and a random sample of resident rooms. There are multiple shaded seating areas for the residents throughout the facility patio area. Passageways and exits are free of obstruction. The water temperature was tested in a random selection of resident bedrooms and measured between 112.4 F - 118.8 F which is within the required 105 F - 120 F degrees. Grab bars and non-skid mats were observed in resident bathrooms. Resident bedrooms have the required furniture such as bed frames, dressers, lamps and chairs. Bedrooms also have sufficient closet space. Resident beds have the required linen and the linen is in good condition. Smoke detectors and carbon monoxide detectors were observed in resident rooms and were tested and operable during the visit. There are multiple fire extinguishers located throughout the facility. Kitchen appliances are clean and were operating at the time of the visit. Sharps are locked and are inaccessible to residents. Cleaning supplies and disinfectants are locked and are inaccessible to the residents. LPA observed a sufficient amount of perishable and non-perishable food supply. Medications were reviewed and appeared to be administered as prescribed. Resident and Staff files have all the required documentation. Ms. Hill stated that the facility conducted an earthquake/fire drill on 8/2/23. There were no deficiencies observed on today's visit. Exit interview conducted and report was given to Ms. Hill.