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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 306005740
Report Date: 04/22/2026
Date Signed: 04/22/2026 12:50:16 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
01/14/2026 and conducted by Evaluator Claudia Gutierrez
PUBLIC
COMPLAINT CONTROL NUMBER: 22-AS-20260114213328
FACILITY NAME:OAKMONT OF ORANGEFACILITY NUMBER:
306005740
ADMINISTRATOR:ANNA PASTORESFACILITY TYPE:
740
ADDRESS:630 THE CITY DRIVE SOUTHTELEPHONE:
(714) 880-8624
CITY:ORANGESTATE: CAZIP CODE:
92868
CAPACITY:155CENSUS: 104DATE:
04/22/2026
UNANNOUNCEDTIME BEGAN:
08:00 AM
MET WITH:Dennis RobeniolTIME COMPLETED:
01:05 PM
ALLEGATION(S):
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Staff did not follow physician's order to monitor resident's blood pressure
Staff falsified resident records
INVESTIGATION FINDINGS:
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An unannounced complaint investigation was conducted on this day by Licensing Program Analyst (LPA) Claudia Gutierrez regarding the allegations mentioned above. LPA met with Executive Director (ED) Dennis Robeniol and Health Services Director (HSD) Angela Boyd.

Regarding the allegation, Staff did not follow physician's order to monitor resident's blood pressure, the following was revealed: It is alleged that Staff did not follow physician's order to monitor Resident 1’s (R1’s) blood pressure. An interview was conducted with R1’s responsible party, Witness 1 (W1), who stated that the facility had informed them they could not accept a verbal request to monitor R1’s blood pressure. Per W1, on January 13, 2026, they provided a printout of the physician’s order, which also had a medical stamp with R1’s care provider information, however, the facility would still not accept it and stated physician’s hand signature was required. Per W1, they were then provided with the incorrect fax number for the facility and by January 19, 2026, one full week of the prescribed monitoring period had passed with no blood pressure readings taken. (Cont. LIC9099-C)
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Lourdes Montoya
LICENSING EVALUATOR NAME: Claudia Gutierrez
LICENSING EVALUATOR SIGNATURE:

DATE: 04/22/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/22/2026
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 5
Control Number 22-AS-20260114213328
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: 04/22/2026
NARRATIVE
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During the course of the investigation, LPA obtained a copy of R1’s physician order dated January 12, 2026, which states, “continue with blood pressure monitoring for the next two weeks.” LPA also obtained a copy of R1’s vital signs readings from January 12, 2026 to January 20, 2026 and observed R1’s blood pressure was only taken on two days, January 19, 2026 and January 20, 2026. During their interview, R1 corroborated the allegation and stated their blood pressure had not been taken during that time frame.

Regarding the allegation, Staff falsified resident records, the following was revealed: It was alleged staff falsely documented R1’s blood pressure readings. During their interview, W1 stated R1’s doctor requested their blood pressure be taken daily for one week due to critically low readings. Per W1, R1’s blood pressure was only taken once between December 27, 2025 and December 31, 2025, however, the report they received on January 2nd, 2026 contained five readings, of which four were falsely presented as if they had been measured. LPA obtained a copy of blood pressure readings in question and observed Staff 3 (S3) had taken R1’s blood pressure on December 27, 2025, December 28, 2025, and December 29, 2025 and Staff 1 (S1) had taken R1’s blood pressure on December 30, 2025 and December 31, 2025. During their interview, S1 corroborated the allegation and stated the blood pressure readings had been falsified, but they were unsure of who had entered them. S1 denied taking R1’s blood pressure during that time frame due to having been on vacation at the time. During their interview, S3 corroborated the allegation and stated the blood pressure readings had been falsified, but they were unsure of who had entered them. Per S3, they did take R1’s blood pressure on December 27, 2025, however, denied having taken R1’s blood pressure on December 28, 2025 or December 29, 2025 as that was their day off. During their interview, R1 also corroborated the allegation and stated their blood pressure had only taken once by S3 on December 27, 2025.

Based on R1’s record review and Staffs’ and R1’s interview, the preponderance of evidence standard has been met; therefore, the above allegations are found to be substantiated. Deficiencies are being cited per Title 22 Division 6 of the California Code of regulations (see LIC9099-D). An exit interview was conducted. A copy of this report, and appeal rights were left at the facility.
SUPERVISORS NAME: Lourdes Montoya
LICENSING EVALUATOR NAME: Claudia Gutierrez
LICENSING EVALUATOR SIGNATURE:

DATE: 04/22/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/22/2026
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 22-AS-20260114213328
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: 04/22/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
04/23/2026
Section Cited
CCR
87464(f)(1)
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(f) Basic services shall at a minimum include: (1) Care and supervision as defined in Section 87101(c)(3) and Health and Safety Code section 1569.2(c).

This requirement is not met as evidenced by:
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ED stated an in-staff service meeting will be held to ensure all physician orders are followed and a copy will be provided to LPA via email by POC date.
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Based on record review and staff and resident interviews, the Licensee did not comply with the section cited above as R1’s physician order to continue with blood pressure monitoring was not followed, which posed an immediate health, safety, and personal rights risk to persons in care.
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Type A
04/23/2026
Section Cited
CCR
87207
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87207 False Claims No licensee, officer or employee of a licensee shall make or disseminate any false or misleading statement regarding the facility or any of the services provided by the facility.

This requirement is not met as evidenced by:
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ED stated staff training will be conducted regarding false claims and accurate record keeping for all residents and a copy will be provided to LPA via email by POC date.
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Based on staff and resident interviews, the Licensee did not comply with the section cited above as staff falsely documented R1’s blood pressure readings, which poses an immediate health, safety, and personal rights risk to persons 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: Lourdes Montoya
LICENSING EVALUATOR NAME: Claudia Gutierrez
LICENSING EVALUATOR SIGNATURE:

DATE: 04/22/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/22/2026
LIC9099 (FAS) - (06/04)
Page: 5 of 5
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
01/14/2026 and conducted by Evaluator Claudia Gutierrez
PUBLIC
COMPLAINT CONTROL NUMBER: 22-AS-20260114213328

FACILITY NAME:OAKMONT OF ORANGEFACILITY NUMBER:
306005740
ADMINISTRATOR:ANNA PASTORESFACILITY TYPE:
740
ADDRESS:630 THE CITY DRIVE SOUTHTELEPHONE:
(714) 880-8624
CITY:ORANGESTATE: CAZIP CODE:
92868
CAPACITY:155CENSUS: 104DATE:
04/22/2026
UNANNOUNCEDTIME BEGAN:
08:00 AM
MET WITH:Dennis RobeniolTIME COMPLETED:
01:05 PM
ALLEGATION(S):
1
2
3
4
5
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7
8
9
Staff mismanaged resident's medication
INVESTIGATION FINDINGS:
1
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3
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5
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7
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12
13
An unannounced complaint investigation was conducted on this day by Licensing Program Analyst (LPA) Claudia Gutierrez regarding the allegations mentioned above. LPA met with Executive Director (ED) Dennis Robeniol and Health Services Director (HSD) Angela Boyd.

It was alleged Staff 1 (S1) mismanaged Resident 1’s (R1’s) medication despite R1 managing their own medication. During the course of the investigation, LPA obtained a copy of R1’s Physician Report dated July 22, 2025, which indicates R1 is able to administer their own prescription medication. During their interview, R1 was unable to identify the staff, however, stated staff had entered their room and requested they cut their blood pressure medication in half. Per R1, W1 had intervened and the medication had not actually been cut in half. During their interview, S1 denied mismanaging R1’s medication and stated they had not attempted to cut R1’s blood pressure medication in half. (Cont. LIC9099-C)
Unfounded
Estimated Days of Completion:
SUPERVISORS NAME: Lourdes Montoya
LICENSING EVALUATOR NAME: Claudia Gutierrez
LICENSING EVALUATOR SIGNATURE:

DATE: 04/22/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/22/2026
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 3 of 5
Control Number 22-AS-20260114213328
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: 04/22/2026
NARRATIVE
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LPA obtained email records between W1 and the former Executive Director, Staff 2 (S2) and on an email dated February 2, 2026, S2 states they asked S1 if they had offered the pill cutter to R1, which S1 admitted, however, there is no indication the medication in question was in fact cut or managed by S1. During their interview, W1 stated that S1 had entered R1’s room with a doctor’s letter indicating R1’s blood pressure medication dose had been decreased and asked R1 to cut their blood pressure medication in half. Per W1, they received a call at the time of the incident and were able to intervene and prevent staff from managing or cutting R1’s medication as R1 already had the decreased dose of the medication and there was no need to cut it half.

The Department has investigated the complaint alleging Staff mismanaged resident's medication. After a review of R1’s records and interviews conducted with staff and witnesses, We have found that the complaint was unfounded, meaning that the allegation was false, could not have happened and/or is without a reasonable basis. An exit interview was conducted. A copy of this report, and appeal rights were left at the facility.
SUPERVISORS NAME: Lourdes Montoya
LICENSING EVALUATOR NAME: Claudia Gutierrez
LICENSING EVALUATOR SIGNATURE:

DATE: 04/22/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/22/2026
LIC9099 (FAS) - (06/04)
Page: 4 of 5