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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198320250
Report Date: 12/16/2025
Date Signed: 12/16/2025 04:48:53 PM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
This is an official report of an unannounced visit/investigation of a complaint received in our office on
10/14/2025 and conducted by Evaluator Wendy Gibbs
COMPLAINT CONTROL NUMBER: 11-AS-20251014150501
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: 78DATE:
12/16/2025
UNANNOUNCEDTIME BEGAN:
08:30 AM
MET WITH:Angelie 'Angel' PasaTIME COMPLETED:
05:00 PM
ALLEGATION(S):
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Staff did not seek medical attention for resident
Staff did not reassess resident's blood pressure in a timely manner
INVESTIGATION FINDINGS:
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On 12/16/2025, Licensing Program Analyst (LPA) Wendy Gibbs conducted an unannounced Complaint Visit to the facility. LPA met with Health Services Director, Angelie ‘Angel’ Pasa, and the purpose of today’s visit was explained. LPA was granted entry into the facility.
The investigation consisted of the following:
During today’s visit, LPA interviewed Staff S1-Staff S8. During a subsequent visit conducted on 11/13/2025, LPA interviewed Residents R1-R8 and received and reviewed resident R1’s Admission Agreement (dated 10/01/2020), On-Site Activity (dated 09/29/2020 through 10/14/2025), Resident Charges/Payment Ledger (dated 10/02/2020 through 11/13/2025), and Charting Notes for R1. During the initial visit conducted on 10/16/2025, LPA inspected the facility and received and reviewed Staff Roster, Resident Roster, Resident Physician’s Report (dated 03/19/2025 and 04/08/25, Physician Orders, Individual Service Plan (dated 08/04/2025 and 07/16/2025), Shift Report (dated 10/06/25 through 10/16/2025), and resident Charting Note (dated 02/09/2025 through 10/10/2025).
The investigation revealed the following:
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Wendy Gibbs
LICENSING EVALUATOR SIGNATURE:

DATE: 12/16/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/16/2025
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 3
Control Number 11-AS-20251014150501
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME: OAKMONT OF TORRANCE
FACILITY NUMBER: 198320250
VISIT DATE: 12/16/2025
NARRATIVE
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During interviews with staff S1-S8, were asked when monitoring a resident how often they check on them, eight (8) out of eight (8) stated the resident is checked every hour when being monitored.
During interviews with Residents R1-R8, were asked if staff assist them when they are not feeling well, eight (8) out of eight (8) stated yes, staff assist them and check on them when they are not feeling well. Additionally, Residents R1-R8 were asked if staff meet their needs, eight (8) out of eight (8) stated yes staff meet their needs.

During the course of the investigation, LPA was unable to find evidence to support the allegation. Although the allegation may have happened or is valid, there is no preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is unsubstantiated.



During today's visit LPA did not observe or cite any deficiencies.

LPA conducted an exit interview with Maintenance Director, Pedro Gonzales, and a copy of this report was provided.
SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Wendy Gibbs
LICENSING EVALUATOR SIGNATURE:

DATE: 12/16/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/16/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 11-AS-20251014150501
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME: OAKMONT OF TORRANCE
FACILITY NUMBER: 198320250
VISIT DATE: 12/16/2025
NARRATIVE
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Allegation: Staff did not seek medical attention for a resident.
The allegation alleges that a resident’s blood pressure was high, and staff did not seek medical attention for the resident.
During record review, LPA received and reviewed the R1’s Charting Notes and observed that when R1’s systolic is elevated over 180 paramedics have been called to assess the resident. LPA observed on 08/02/2025, 10/04/2025, and 10/07/2025 paramedics were called to assess R1 and provide transfer to the emergency room. During an interview with Staff S2 stated that when they checked on R1 a second time, before leaving for the day, R1 stated they were feeling a little better but wanted to rest a little while longer.
During interviews with Staff S1-S8, were asked if resident’s receive medical attention in a timely manner, eight (8) out of eight (8) stated yes residents receive medical treatment in a timely manner.
During interviews with Residents R1-R8, were asked if staff ensure they get medical attention if needed in a timely manner, eight (8) out of eight (8) stated yes, staff ensure they get medical attention when needed. Additionally, Resident R1-R8 were asked if there had been a time they did not get medical attention when needed, eight (8) out of eight (8) stated no, they have always received medical attention.

During the course of the investigation, LPA was unable to find evidence to support the allegation. Although the allegation may have happened or is valid, there is no preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is unsubstantiated



Allegation: Staff did not reassess resident’s blood pressure in a timely manner.
The allegation alleges that staff took a resident’s blood pressure and said they would be back in an hour to check on the resident and did not come back.
During record review, LPA received and reviewed the Med Tech’s Shift Report for 10/12/2025 that states for the Notes (Day) “BP was high (159/60) [R1] said [they were] feeling flush. No fatigue, headache or pain. Elevated feet in supine position on the bed.” The shift notes for the Notes (PM) stated “BP was checked x2. First time was 141/64 second time was 154/60. Had resident elevate legs + rest + drink water.” During an interview with Staff S2, was asked how many times they checked on R1 when they reported they were not feeling well, S2 stated R1 informed them they were not feeling well at 1:50pm and they took R1’s blood pressure, assisted with elevating their legs and provided water. R1 stated they updated the next shift at crossover then went to check on R1 at 2:20pm before they got off shift.
SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Wendy Gibbs
LICENSING EVALUATOR SIGNATURE:

DATE: 12/16/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/16/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 3