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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 079201085
Report Date: 07/02/2025
Date Signed: 07/02/2025 03:43:28 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
11/16/2021 and conducted by Evaluator Alicia Delmundo
COMPLAINT CONTROL NUMBER: 15-AS-20211116122617
FACILITY NAME:OAKMONT OF CONCORDFACILITY NUMBER:
079201085
ADMINISTRATOR:STICKA, ANGELESFACILITY TYPE:
740
ADDRESS:1401 CIVIC COURTTELEPHONE:
(925) 798-4004
CITY:CONCORDSTATE: CAZIP CODE:
94520
CAPACITY:121CENSUS: 94DATE:
07/02/2025
UNANNOUNCEDTIME BEGAN:
02:35 PM
MET WITH:San Sor/Executive DirectorTIME COMPLETED:
03:45 PM
ALLEGATION(S):
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Residents sustain unexplained injuries while in care.
Staff did not provide medical attention to resident in a timely manner.
Staff mismanage resident's medication.
Resident not administered medication as prescribed.
Residents' medication records not complete.
Residents' medical assessments outdated.
INVESTIGATION FINDINGS:
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On this day, 7/02/25, at 2:35 pm, Licensing Program Analyst (LPA) Delmundo arrived unannounced to deliver the findings for the above allegations. LPA met with Executive Director (ED) San Sor, and informed the reason for visit.

During the course of investigation, LPA obtained copies of resident roster. LPA reviewed residents records and obtained copies of including but not limited to Resident Information Forms, doctor’s orders of medications, Medication Administration Records (MARs) and staff notes/documentations, hospital After Visit Summary, facility communication to residents’ doctors. LPA conducted inspection on 11/19/21 and interviewed staff (S1, S2), previous Memory Care Director (FMCD) and residents (R1 and R2).


.......continued on 9099C(page 2)
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Alicia Delmundo
LICENSING EVALUATOR SIGNATURE:

DATE: 07/02/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/02/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 4
Control Number 15-AS-20211116122617
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 CONCORD
FACILITY NUMBER: 079201085
VISIT DATE: 07/02/2025
NARRATIVE
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Page 2

Allegation: Residents sustained unexplained injuries while in care.
Allegation: Staff did not provide medical attention to resident in a timely manner.

Reporting party (RP) stated residents sustain skin tear, bruising and no one will report to the doctor until later and no one will follow-up.

FMCD stated there’s no resident specifically in Memory Care (MC) sustained unexplained injury and/or bruising. FMCD stated there’s a resident in MC who sustained bruising on 11/19/21 and was reported to her that same day. FMCD further stated that will enter it internally and when she entered it, it's automatic that the Health Services Director will see it and HSD will submit the report to Community Care Licensing. The 2 staff stated when residents have incidents, the facility nurse assess and staff call 9-1-1 when needed. One of these 2 staff stated that if a resident sustains unexplained injury and/or bruising, the caregiver reports to the med-tech who in turn reports to the primary care physician. The 2 residents interviewed stated when they need help, the staff assist. Therefore, the above allegations are unsubstantiated.



Allegation: Staff mismanage resident's medication.
Allegation: Resident not administered medication as prescribed.
Allegation: Residents' medication records not complete.

RP stated the med-room is a mess, residents run out of medication due to pharmacy is not on top of it and residents not administered medication. RP also stated that the Central Log for medications is a mess and no dates medications were started.

.....continued 9099C (page 3)

SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Alicia Delmundo
LICENSING EVALUATOR SIGNATURE:

DATE: 07/02/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/02/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 4
Control Number 15-AS-20211116122617
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 CONCORD
FACILITY NUMBER: 079201085
VISIT DATE: 07/02/2025
NARRATIVE
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Page 3

One of 2 staff stated the residents medications are refilled 5 to 7 days before they run out. The facility has an in-house pharmacy but some residents/family members have their preferred pharmacy. This staff and the other staff both stated residents missed medications due to insurance issues and family members not delivering the medications timely.

During inspection, LPA observed the med-room organized. LPA reviewed the MARs and checked with the med-tech the information entered in the computer which showed including but not limited to Alert Charting, medications that were discontinued and medications refusals. Although hard copies of LIC622 LPA obtained some not having dates medications started, however, the information were entered in the computer. Therefore, the 3 allegations are unsubstantiated.

Allegation: Residents' medical assessment outdated.

Previous staff worker stated assessments are not being done timely.

LPA selected 4 residents and reviewed their records which showed LIC602A Medical Assessments were less than a year old. Assessments were up to date. Therefore, the allegation is unsubstantiated.

A finding that a complaint is unsubstantiated means that although the allegations may have happened or valid, there is not a preponderance of evidence to prove that violations occurred.

No deficiency cited.

Exit interview conducted and copy of this report provided.

SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Alicia Delmundo
LICENSING EVALUATOR SIGNATURE:

DATE: 07/02/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/02/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 4
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
11/16/2021 and conducted by Evaluator Alicia Delmundo
COMPLAINT CONTROL NUMBER: 15-AS-20211116122617

FACILITY NAME:OAKMONT OF CONCORDFACILITY NUMBER:
079201085
ADMINISTRATOR:STICKA, ANGELESFACILITY TYPE:
740
ADDRESS:1401 CIVIC COURTTELEPHONE:
(925) 798-4004
CITY:CONCORDSTATE: CAZIP CODE:
94520
CAPACITY:121CENSUS: 94DATE:
07/02/2025
UNANNOUNCEDTIME BEGAN:
02:35 PM
MET WITH:San Sor/Executive DirectorTIME COMPLETED:
03:45 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Biohazard trash are not disposed properly.
INVESTIGATION FINDINGS:
1
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13
On this day, 7/02/25, at 2:35 pm, Licensing Program Analyst (LPA) Delmundo arrived unannounced to deliver the findings for the above allegation. LPA met with Executive Director (ED) San Sor, and informed the reason for visit.

LPA conducted inspection on 11/19/21 and interviewed staff (S1, S2) and previous Memory Care Director (FMCD).

FMCD stated the sharps container were kept and stored in bigger box in the med-room and biohazard company picks it up. The 2 staff stated the biohazard trash were kept in biohazard container. These statements were confirmed by LPA upon inspection. LPA observed the biohazard trash and used insulin needles in biohazard container in the med-room.Therefore, the allegation in unfounded.

No deficiency cited. Exit interview conducted and copy of this report provided.
Unfounded
Estimated Days of Completion:
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Alicia Delmundo
LICENSING EVALUATOR SIGNATURE:

DATE: 07/02/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/02/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 4 of 4