306005740-5-18-2026-22-AS-APAO-DURUZU-20260605160208

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 306005740
Report Date: 05/18/2026
Date Signed: 05/18/2026 04:39:53 PM

Unsubstantiated

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
07/06/2023 and conducted by Evaluator Jenifer Tirre

PUBLIC

COMPLAINT CONTROL NUMBER: 22-AS-20230706083051

FACILITY NAME:	OAKMONT OF ORANGE		FACILITY NUMBER:	306005740
ADMINISTRATOR:	ALYSON CALUZA		FACILITY TYPE:	740
ADDRESS:	630 THE CITY DRIVE SOUTH		TELEPHONE:	(714) 880-8624
CITY:	ORANGE	STATE: CA	ZIP CODE:	92868
CAPACITY:	155	CENSUS: 100	DATE:	05/18/2026
		UNANNOUNCED	TIME BEGAN:	07:41 AM
MET WITH:	Executive Director Dennis Robeniol		TIME COMPLETED:	05:00 PM

ALLEGATION(S):

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Resident sustained multiple falls while in care
Staff neglected resident while in care

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Jenifer Tirre conducted an unannounced visit to deliver findings on an investigation. LPA was greeted and granted entry into the facility by staff and explained the reason of the visit with Executive Director Dennis Robeniol

During course of the investigation, the Department reviewed & obtained records including Physician’s report, fall risk evaluation assessment, Resident assessment, charting notes, hospital records and service plan. Department also interviewed staff and witness. The investigation revealed the following regarding allegations: Resident sustained multiple falls while in care and Staff neglected resident while in care:
Regarding Resident sustained multiple falls while in care: Based on resident records, Resident was fully independent of mobility back on 5/29/2020 upon admission to facility. R1 had a Fall Risk Evaluation assessment back on 3/22/22 where resident scored 8 indicating high risk of falling. At the time service plan interventions were put into place.
CONTINUED ON 9099C

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Lourdes Montoya
LICENSING EVALUATOR NAME: Jenifer Tirre
LICENSING EVALUATOR SIGNATURE:	DATE: 05/18/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/18/2026

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 22-AS-20230706083051

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: 05/18/2026

NARRATIVE

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Six months later R1 was assessed again for Fall Risk Evaluation and scored a 3, indicating Minimal Risk of falling. R1’s charting notes stated that R1 had a fall on October 28, 2022 , where resident tripped on a rug but got up immediately and underwent a Physical therapy assessment where therapist noted R1 is alert oriented x3 and demonstrates poor safety awareness due to impulsive movement. Physical Therapist recommended R1 to improve safety by using an assistive device such as cane or walker. On 7/3/2023 Hospital Records stated that R1 had tripped over themselves causing an unwitnessed fall. R1 went to hospital. On 7/12/2023 Facility conducted a assessment on R1 due to a change in condition with behaviors and mobility issues. Residents Needs and Service Plan was updated same day 7/12/2023 indicating R1 needs assistance in grooming, dressing, assist with transfers, frequent checks throughout shifts and documentation by staff.

Per staff interviews, one of four staff members recalled R1 and stated that they were in assisted living and remembers R1 being independent of their Activities of daily living (ADL’s) for a long time and it wasn’t till the last few months of R1 requiring assistance due to mobility issues.

Regarding Staff neglected resident while in care: Based on records reviewed, R1 was independent up till their unwitnessed fall on 7/3/2023. R1 had charting notes dated from 1/16/22 to 7/10/2023, where care providers logged notes on type of care or behaviors monitored by staff. R1 also had a home health agency that came out weekly to monitor R1’s foot sore on left foot. On 6/19/2023, R1 was admitted to Hospice due to generalized weakness. Hospice notes also indicated type of care provided.

Per staff interviews, four of four staff members stated that Residents who are a fall risk are typically checked in on & monitored every half hour. One of four staff mentioned that R1 was fairly independent and had a change of condition towards their last month. Per SOC 341, R1’s family member stated that they had no concerns regarding care provided at facility.

Based on information gathered from complaint, the allegations Resident sustained multiple falls while in care and Staff neglected resident while in care were deemed Unsubstantiated meaning that although the allegation may have happened or is valid, there is no preponderance of evidence to prove the alleged violation did or did not occur as reported.

An exit interview was conducted with Activity Director Rebecca Lint and copy of report was provided.

SUPERVISORS NAME: Lourdes Montoya
LICENSING EVALUATOR NAME: Jenifer Tirre
LICENSING EVALUATOR SIGNATURE:	DATE: 05/18/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/18/2026

LIC9099 (FAS) - (06/04)

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