198320250-9-17-2025-11-AS-EMAZ-DMRVLF-20251024163152

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198320250
Report Date: 09/17/2025
Date Signed: 09/17/2025 05:23:57 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
09/09/2025 and conducted by Evaluator Wendy Gibbs

COMPLAINT CONTROL NUMBER: 11-AS-20250909113956

FACILITY NAME:	OAKMONT OF TORRANCE		FACILITY NUMBER:	198320250
ADMINISTRATOR:	JUDITH UY-VILLARUZ		FACILITY TYPE:	740
ADDRESS:	3620 LOMITA BLVD		TELEPHONE:	(424) 376-3300
CITY:	TORRANCE	STATE: CA	ZIP CODE:	90505
CAPACITY:	126	CENSUS: 80	DATE:	09/17/2025
		UNANNOUNCED	TIME BEGAN:	09:01 AM
MET WITH:	Judith Uy		TIME COMPLETED:	05:00 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Due to lack of supervision, resident physically assaulted another resident

INVESTIGATION FINDINGS:

1
2
3
4
5
6
7
8
9
10
11
12
13

On 09/17/2025, Licensing Program Analyst (LPA), Wendy Gibbs, conducted an unannounced subsequent Complaint Visit to the facility listed above. LPA met with Executive Director, Judith Uy, 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 S4-S7, interviewed Residents R2, R8-R10, and received staff In-Service Training logs.
During an initial visit conducted on 09162025, LPA interviewed Staff S1-S3 and S8, interviewed Residents R1-R7, interviewed Psychiatric Nurse Practitioner from Access Healthcare Associates and received documents pertinent to the investigation. The following documents were received and reviewed Staff Roster, Resident Roster, Staff Schedule, Physician’s Report, Physician’s Orders, Preplacement Appraisal Information (dated , Behavioral Expression Appraisal (dated 02/12/2025 and 09/07/2026), Resident Assessment (dated 08/03/2025), Individualized Service Plan (dated 08/03/’2025, 05/18/2025, and 02/20/2025), Progress Notes (dated 08/04/2025 through 09/07/2025), Medication Administration Record

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Wendy Gibbs
LICENSING EVALUATOR SIGNATURE:	DATE: 09/17/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/17/2025

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-20250909113956

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: 09/17/2025

NARRATIVE

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

(MAR) (dated 09/01/2025 through 09/16/2025), Senior Doc documents (dated 08/01/2025, 08/04/2025, and 08/05/2025), and Torrance Police Department card with Case # 250832470 (dated 09/06/2025).
The investigation revealed the following:
Allegation: Due to lack of supervision, resident physically assaulted another resident
The allegation alleges that a resident was assaulted by another resident due to staff not supervising residents.
During the facility visit from 9:15am till 10:30am, LPA observed staff and residents in the Memory Care Unit. LPA observed five (5) care partners and one (1) med tech working. LPA observed in the common area the activity coordinator was conducting activities, and a care partner was observing residents and available if any residents require assistance. LPA observed four (4) care partners escorting residents in and out of the activity room, providing assistance.
During record review, LPA received and reviewed resident R2’s Individualized Service Plan (ISP) dated 08/03/2025, that indicates R2 requires escorting to and from all meals and activities. The ISP indicates R2 receives monitoring and assistance with mood and socialization capabilities due to preferring to be alone. Instructions for support when R2 is observed feeling expressive is to offer the interventions that will support. Additionally on the ISP, it was observed R2 has combative episodes and during their expressive behaviors staff are to redirect R2 in the right direction to prevent future encounters. LPA received and reviewed R2’s Physician’s Report dated 05/20/2025, that indicates R2 has Dementia and is confused and disoriented. LPA received and reviewed staff In-Service logs dated 09/07/2025 regarding Aggressive Behaviors. Additionally, LPA received and reviewed the training logs for Staff S4-S8 and observed four (4) out of four (4) have recent training of “Alzheimer’s Disease and Related Disorders: Psychosocial Needs,” Alzheimer’s Disease and Related Disorders: ADLs and Behaviors,” and “Alzheimer’s Disease and Related Disorders: Behaviors.” LPA received and reviewed an Unusual Incident/Injury Report for an altercation that occurred on 09/06/2025 between R1 and R2. Resident R2 was being escorted to their room from the dining area when their wheel got stuck on the leg of the chair R1 was sitting on. R1 stood up to give more room to R2 when R2 suddenly struck R1. R2 was escorted to their room and R1 was evaluated and provided first aid.
During interviews with Staff S1-S8, were asked if they feel there is enough staff to provide supervision to residents to prevent altercations between residents, eight (8) out of eight (8) stated yes, they have enough staff to provide supervision to prevent altercations. Additionally, during interviews with Staff S1-S8, were asked if they have received training regarding emotional expression, eight (8) out of eight (8) stated they have received training regarding Dementia and emotional expressions.

SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Wendy Gibbs
LICENSING EVALUATOR SIGNATURE:	DATE: 09/17/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/17/2025

LIC9099 (FAS) - (06/04)

Page: 2 of 3

Control Number 11-AS-20250909113956

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: 09/17/2025

NARRATIVE

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

During interviews with Residents R1-R10, were asked if they feel there is enough staff to supervise residents to prevent altercations, eight (8) out of ten (10) stated yes, they feel there is enough staff to prevent altercations between residents. Additionally, Residents R1-R10 were asked if they feel safe living here in the facility, ten (10) out of ten (10) stated yes, they feel safe living in this facility.

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.

LPA did not observe or cite any deficiencies.

An exit interview was conducted with Executive Director, Judith Uy, and a copy of this report was provided.

SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Wendy Gibbs
LICENSING EVALUATOR SIGNATURE:	DATE: 09/17/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/17/2025

LIC9099 (FAS) - (06/04)

Page: 3 of 3