306005740-4-1-2026-22-AS-SSAS-DST3Y8-20260403183932

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 306005740
Report Date: 04/01/2026
Date Signed: 04/01/2026 04:49:15 PM

Substantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

This is an official report of an unannounced visit/investigation of a complaint received in our office on
01/22/2026 and conducted by Evaluator Brandon Lopez

PUBLIC

COMPLAINT CONTROL NUMBER: 22-AS-20260122100814

FACILITY NAME:	OAKMONT OF ORANGE		FACILITY NUMBER:	306005740
ADMINISTRATOR:	ANNA PASTORES		FACILITY TYPE:	740
ADDRESS:	630 THE CITY DRIVE SOUTH		TELEPHONE:	(714) 880-8624
CITY:	ORANGE	STATE: CA	ZIP CODE:	92868
CAPACITY:	155	CENSUS: 105	DATE:	04/01/2026
		UNANNOUNCED	TIME BEGAN:	01:45 PM
MET WITH:	Health Services Director Angela Boyd		TIME COMPLETED:	05:00 PM

ALLEGATION(S):

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Staff mismanaged resident's medications.
Staff did not respond to resident's call button in a timely manner.

INVESTIGATION FINDINGS:

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On April 1, 2026, Licensing Program Analyst (LPA) Brandon Lopez made an unannouned visit to the facility to continue the investigation into the allegations listed above and to deliver the complaint findings. LPA was greeted and granted entry into the facility by staff after explaining the purpose for the visit. Health Services Director Angela Boyd was present and assisted on today's visit.

During the course of the investigation, LPA conducted seven resident interviews, six staff interviews, reviewed and collected pertinent documents for this complaint. Regarding the allegation, staff mismanaged resident's medications, the following has been concluded: It was alleged that staff mismanaged Resident #1 (R1) medication on September 2023, April 2025, and August 2025. LPA reviewed the medication administration records for R1 for September 2023, April 2025, and August 2025. LPA observed that the facility did not provide R1 her presribed Vitamin D3 medication on September 13, 2023, due to the facility not having the medication on hand, despite R1 having active orders for the medication.
CONTINUED ON LIC9099-C

Substantiated

Estimated Days of Completion: 90

SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Brandon Lopez
LICENSING EVALUATOR SIGNATURE:	DATE: 04/01/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/01/2026

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 22-AS-20260122100814

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: OAKMONT OF ORANGE	FACILITY NUMBER: 306005740
	VISIT DATE: 04/01/2026

NARRATIVE

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LPA also observed that the facility did not provide R1 her prescribed Olopatadine solution medication on April 20, and April 21, 2025, due to the facility not having the medication on hand, despite R1 having active orders for the medication. LPA conducted an interview with R1. R1 corroborated the allegation and reported that her medications were not given to her as prescribed on multiple occasions. LPA conducted six staff interviews. Four out of the six staff interviewed denied the allegation. However, two out of the six staff interviewed corroborated the allegation and reported that there were previous medication errors with R1's medication.

Regarding the allegation, staff did not respond to resident's call button in a timely manner, the following has been concluded: It was alleged that staff did not respond to R1's call button in a timely manner on November 2022 and on July 2023. The facility was unable to provide any call button records for R1 from November 2022 or July 2023 due to their system not storing records for more than thirty days. However, LPA was able to obtain email records between the Reporting Party (RP) and the former Health Services Director, Staff #7 (S7). On an email dated November 18, 2022, S7 admits to the RP that it took staff forty three minutes to respond to R1's call button request on November 16, 2022. On an email dated July 17, 2023, S7 admits to the RP that it took staff ninety minutes to respond to R1's call button request on July 16, 2023. On an email dated September 20, 2025, S7 admits to the RP that it took staff forty five minutes to respond to R1's call button request earlier that day. LPA conducted an interview with R1. R1 corroborated the allegation and reported that she has had to wait extended periods of times to be assisted by staff after she presses her call button. LPA conducted an six staff interviews. Two out of the six staff interviewed denied the allegation. However, four out of the six staff interviewed corroborated the allegation and acknowledged that there have been incidents in which residents have had to wait extended periods of times to be assisted after pressing their call buttons.

Based on the evidence gathered during this investigation, the Department obtained sufficient evidence to substantiate the allegations that, staff mismanaged resident's medications, and staff did not respond to resident's call button in a timely manner. The preponderance of evidence standards has been met; therefore, the above allegations are SUBSTANTIATED. Deficiencies are being cited on the attached LIC9099-D page. An exit interview was conducted with Health Services Director Angela Boyd. A copy of the report and Appeal Rights were provided.

SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Brandon Lopez
LICENSING EVALUATOR SIGNATURE:	DATE: 04/01/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/01/2026

LIC9099 (FAS) - (06/04)

Page: 2 of 3

Control Number 22-AS-20260122100814

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: OAKMONT OF ORANGE	FACILITY NUMBER: 306005740
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 04/01/2026

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 04/02/2026 Section Cited CCR 87465(a)(4)	1 2 3 4 5 6 7	87465 Incidental Medical and Dental Care :(a) A plan for incidental medical and dental care shall be developed by each facility...(4) The licensee shall assist residents with self-administered medications as needed. This requirement was not evidenced by:	1 2 3 4 5 6 7	The Health Services Director stated that she will conduct an in service training with all staff regarding medication management. The Health Services Director agreed to provide LPA proof of training via email or fax by POC date.
	8 9 10 11 12 13 14	Based on records reviewed, the Licensee did not ensure that R1's medications were given as presribed on 09/13/23, 04/20/25, and 04/21/25. This poses an immediate health and safety risk to persons in care.	8 9 10 11 12 13 14
Type B 04/10/2026 Section Cited CCR 87411(a)	1 2 3 4 5 6 7	87411 Personnel Requirements – General (a) Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs... This requirement is not evidenced by:	1 2 3 4 5 6 7	The Health Services Director stated that she will conduct an in service training with all staff regarding reponding to call buttons timely. The Health Services Director agreed to provide LPA proof of training via email or fax by POC date.
	8 9 10 11 12 13 14	Based on records reviewed, the Licensee did not ensure that R1 was assisted in a timely manner after pressing her call button. This poses a potential health and safety risk to persons in care.	8 9 10 11 12 13 14

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: Sheila Santos
LICENSING EVALUATOR NAME: Brandon Lopez
LICENSING EVALUATOR SIGNATURE:	DATE: 04/01/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/01/2026

LIC9099 (FAS) - (06/04)

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