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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198320250
Report Date: 10/16/2025
Date Signed: 10/16/2025 11:23:23 AM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245
This is an official report of an unannounced visit/investigation of a complaint received in our office on
03/24/2025 and conducted by Evaluator Lizeth Villegas
COMPLAINT CONTROL NUMBER: 11-AS-20250324160525
FACILITY NAME:OAKMONT OF TORRANCEFACILITY NUMBER:
198320250
ADMINISTRATOR:JUDITH UY-VILLARUZFACILITY TYPE:
740
ADDRESS:3620 LOMITA BLVDTELEPHONE:
(424) 376-3300
CITY:TORRANCESTATE: CAZIP CODE:
90505
CAPACITY:126CENSUS: 80DATE:
10/16/2025
UNANNOUNCEDTIME BEGAN:
09:37 AM
MET WITH:Executive Director Judy UyTIME COMPLETED:
11:21 AM
ALLEGATION(S):
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Staff sexually abused resident in care.
INVESTIGATION FINDINGS:
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On 10/16/2025, at 9:30 am, the department made an unannounced subsequent visit to the facility and was greeted by Executive Director, Judy Uy. The purpose of today’s visit was to deliver findings in the complaint investigation.

The investigation consisted of the following: On 03/25/25 at 08:25am, the department conducted an initial visit and met with Judy Uy, Executive Director. During the initial visit, the department conducted a health and safety tour of the facility’s Memory Care Unit and observed residents in care. The department obtained copies of the following documents: Staff Roster (Dated: 02/25/2025), Staff Schedule for (03/16/2025 to 03/29/2025), Resident Roster (Dated: 03/24/2025), Personal Data Form for staff (S1), Termination Letter for S1 (Dated: 03/24/2025), Employment Application (Dated: 11/25/2024), Disciplinary Action Notice (Dated: 02/10/2025), Relias Training Transcript (Various Dates), Resident Information Form, Physician’s Report for resident (R1) (Dated: 03/20/2024), Physician’s Orders for R1 (Dated: 03/24/2025), Resident Assessment (Dated: 06/30/2024), Individualized Resident Service Plan (Dated: 06/30/2025), Resident Charting Notes
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Lizeth Villegas
LICENSING EVALUATOR SIGNATURE:

DATE: 10/16/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/16/2025
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 11-AS-20250324160525
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245
FACILITY NAME: OAKMONT OF TORRANCE
FACILITY NUMBER: 198320250
VISIT DATE: 10/16/2025
NARRATIVE
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(Dated: 12/31/2024 to 03/23/2025), Staff In-Service Log (Dated: 03/23/2025), Torrance Police Department Case Information/Supplemental (Dated: 03/23/2025), and Forensic Nurse Specialist, INC discharge documents (Dated:03/23/2025) from the facility.

The complaint was referred to the California Department of Social Services Investigation Bureau for investigation and was assigned to Investigation Bureau Investigator, Sonia Torre. As a part of the investigation, Investigator Torre obtained Torrance Police Department records (911 audio, Interrogation footage, Evidence receipts,) and subpoenaed Sexual Assault Response Team (SART) exam records for suspect and victim. The investigator obtained other related documents pertinent to the investigation. Additionally, the investigator conducted interviews with staff (S1-S9), witness (W1), and residents (R1-R3).

The investigation revealed the following: Allegation- Staff sexually abused resident in care.

It is alleged that a staff member (S1) sexually abused a resident (R1) while in care at the residential facility. It was reported that the staff (S1) was found in the residents (R1) room by a staff member with their pants down while the resident was lying in bed. On 04/15/25, from 10:33am-12:55pm, the department interviewed staff (S2-S6) and residents (R1-R3); On 5/27/25, at 03:00pm, the department interviewed witness (W1), On 6/18/25 from 9:54am-12:30pm, the department interviewed staff (S7-S9), and on 6/26/25 at 11:56am, the department interviewed former staff (S1) about the complaint allegation.

During the course of the investigation, records were reviewed, and interviews were conducted with staff, residents, and former staff. The review of the facility records Disciplinary Action Notice (Dated: 02/10/2025), revealed staff (S1) had been disciplined for being in a resident’s room (unoccupied) for a prolong period of time during their shift. The review of Torrance Police Department records revealed staff (S2) stated that, at approximately 11:20am, they were attempting to contact staff (S1) via the radio with no success, which was not uncommon. Approximately ten minutes later, (S2) decided to search for (S1) and noticed the door to (R1s) room was locked. (S2) unlocked the door and when they walked in (S2) observed (S1) standing beside the bed with their pants and underwear pulled down just below their buttocks exposing their entire buttocks with resident (R1) who was wearing a diaper and shirt laying on the bed on their right side facing away from (S1). (S2) immediately walked out, reported the incident to staff, management and Torrance PD. S1 denied the allegation that staff sexually abused resident in care but was ultimately arrested by the Torrance Police department.

SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Lizeth Villegas
LICENSING EVALUATOR SIGNATURE:

DATE: 10/16/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/16/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 4
Control Number 11-AS-20250324160525
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245
FACILITY NAME: OAKMONT OF TORRANCE
FACILITY NUMBER: 198320250
VISIT DATE: 10/16/2025
NARRATIVE
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Based on interviews conducted, and records reviewed, the preponderance of evidence standard has been met. Therefore, the above allegation Staff sexually abused resident in care, is found to be Substantiated. California code of Regulation, (Tittle 22, Division 6 & Chapter 8), are being cited on the attached LIC 9099D.

Deficiencies are issued and plans of corrections were discussed.


An exit interview was conducted, appeal rights explained, and a copy of this Report was provided to Executive Director, Judy Uy.
SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Lizeth Villegas
LICENSING EVALUATOR SIGNATURE:

DATE: 10/16/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/16/2025
LIC9099 (FAS) - (06/04)
Page: 4 of 4
Control Number 11-AS-20250324160525
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245

FACILITY NAME: OAKMONT OF TORRANCE
FACILITY NUMBER: 198320250
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/16/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Request Denied
Type A
10/17/2025
Section Cited
CCR
87468.1(a)(3)
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87468.1 Personal Rights of Residents in All Facilities: Residents in all residential care facilities for the elderly shall have all of the following personal rights:To be free from punishment, humiliation, intimidation, abuse, or other actions of a punitive nature, such as withholding...this requirement is not met
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Licensee/ Executive Director to retrain all staff on resident rights and submit proof to LPA of training: staff sign in sheet and material(s) covered. Licensee/ Executive Director to review regulation cited and submit plan to CCLD detailing how facility will get into compliance with title 22 regulations.
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as evidenced by: Based on interviews and records reviewed facility S1 sexually abused R1 while resident was in care. S1 exposed themselves in R1’s room and was found by facility staff. This poses an immediate health & safety risk to residents in care.

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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Lizeth Villegas
LICENSING EVALUATOR SIGNATURE:

DATE: 10/16/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/16/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 4