019201084-9-4-2025-15-AS-YFLS-DLTNA7-20250924101700

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 019201084
Report Date: 09/04/2025
Date Signed: 09/04/2025 02:57:22 PM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

This is an official report of an unannounced visit/investigation of a complaint received in our office on
03/27/2025 and conducted by Evaluator Gregory Clark

COMPLAINT CONTROL NUMBER: 15-AS-20250327161639

FACILITY NAME:	OAKMONT OF MARINER POINT		FACILITY NUMBER:	019201084
ADMINISTRATOR:	HAN, MINDY M		FACILITY TYPE:	740
ADDRESS:	2400 MARINER SQUARE DRIVE		TELEPHONE:	(510) 347-5959
CITY:	ALAMEDA	STATE: CA	ZIP CODE:	94502
CAPACITY:	80	CENSUS: 43	DATE:	09/04/2025
		UNANNOUNCED	TIME BEGAN:	11:00 AM
MET WITH:	Juan Ferrel, Interim Administrator		TIME COMPLETED:	12:00 PM

ALLEGATION(S):

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Resident sustained unexplained laceration
Staff did not seek timely medical treatment for resident
Staff are not providing adequate assistance to resident during feeding times
Staff are not properly supervising residents who may be a fall risk
Staff are not meeting residents dietary needs

INVESTIGATION FINDINGS:

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On 9/04/2025 at 1:30 PM Licensing Program Analyst (LPA) Greg Clark arrived unannounced to deliver findings for the above complaint. LPA met with Juan Ferrel, Interim Administrator and explained the purpose of the visit.

During the course of the investigation LPA interviewed W1, W2, S1 and S2. There were no other staff available to interview that were employed at the facility during R1’s time there. LPA was unable to interview R1 as she had passed away.

R1 was admitted to the facility on 6/10/24 into the Assisted Living part of the facility. On 9/24/24 R1 was moved to the Memory Care side of the facility due to complications due to a fall. (LPA did receive LIC624 for this incident) From that time forward there were 3 more moves between Memory Care and Assisted Living.
***report continues on LIC9099C***

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Gregory Clark
LICENSING EVALUATOR SIGNATURE:	DATE: 09/04/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/04/2025

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 15-AS-20250327161639

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: OAKMONT OF MARINER POINT	FACILITY NUMBER: 019201084
	VISIT DATE: 09/04/2025

NARRATIVE

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***report continues from LIC9099***

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***

SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Gregory Clark
LICENSING EVALUATOR SIGNATURE:	DATE: 09/04/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/04/2025

LIC9099 (FAS) - (06/04)

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Control Number 15-AS-20250327161639

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: OAKMONT OF MARINER POINT	FACILITY NUMBER: 019201084
	VISIT DATE: 09/04/2025

NARRATIVE

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***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.

SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Gregory Clark
LICENSING EVALUATOR SIGNATURE:	DATE: 09/04/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/04/2025

LIC9099 (FAS) - (06/04)

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