306005740-5-21-2026-22-AS-APAO-DUS2E5-20260605171922

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 306005740
Report Date: 05/21/2026
Date Signed: 05/21/2026 03:24:01 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
10/10/2024 and conducted by Evaluator Claudia Gutierrez

PUBLIC

COMPLAINT CONTROL NUMBER: 22-AS-20241010090602

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: 96	DATE:	05/21/2026
		UNANNOUNCED	TIME BEGAN:	07:30 AM
MET WITH:	Dennis Robeniol		TIME COMPLETED:	01:00 PM

ALLEGATION(S):

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Resident sustained multiple falls while in care due to staff neglect

INVESTIGATION FINDINGS:

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An unannounced Complaint Investigation was conducted on this day by Licensing Program Analyst (LPA) Claudia Gutierrez for the purpose of delivering findings. LPA met with Executive Director (ED) Dennis Robeniol and explained the purpose of the inspection.

Complaint alleges Resident 1 (R1) sustained multiple falls while in care due to staff neglect.

During the course of the investigation, interviews were conducted with R1, one witness, and two staff. During their interview, R1’s responsible party, Witness 1 (W1), was unable to confirm or deny if R1 had sustained multiple falls due to staff neglect. Per W1, R1 may have sustained a fall in May 2024 and October 2024, however, stated they could not recall any of the details regarding the falls. W1 stated that per R1's Care Plan, staff should be conducting routine checks, which consist of staff checking on R1 on a regular basis and reporting back to W1 in the event of a fall. (Cont. LIC9099-C)

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Lourdes Montoya
LICENSING EVALUATOR NAME: Claudia Gutierrez
LICENSING EVALUATOR SIGNATURE:	DATE: 05/21/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/21/2026

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-20241010090602

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: 05/21/2026

NARRATIVE

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Per W1, when they are personally present at the facility, staff routinely check on R1, however, stated they did not know if staff routinely check on R1 when they are not present at the facility. During their interview, R1 denied ever sustaining a fall and stated if they did, “it was a long time ago” and could not remember. LPA obtained a copy of Incident Report (LIC624) which indicated that on May 11, 2024, R1 had an unwitnessed fall in their bedroom and had been found as a dining room tray was being delivered to their room. LIC624 identifies S1 as the person who observed the incident, however, S1 is no longer employed at the facility. Three separate attempts were made to reach S1 by phone, however, S1 could not be reached to confirm or deny the allegation. LPA obtained a copy of a separate LIC624, which indicated that on October 8, 2024, R1 had an unwitnessed fall in their bedroom and had been found on the floor by Staff 2 (S2) as they were conducting routine checks. During their interview, S2 stated they could not recall specific details regarding the incident, however, stated routine checks are conducted for R1 during shifts and R1 is also escorted to meals and activities by staff, which enables staff to conduct additional checks on R1. LPA obtained a copy of Individualized Service Plan (ISP) for R1, which indicates R1 is at moderate risk for falling, and is to be provided with a status check each shift and escorted to meals and activities. Per ISP, fall management protocol consists of ensuring R1 is using assistive mobility devices at all times, reminding and encouraging R1 to use pendant to call for staff assistance, and staff continuing with frequent check-ins. During their interview, Staff 3 (S3) stated they did not have any knowledge regarding R1’s fall on May 11, 2024 or October 8, 2024, however, stated that due to R1’s moderate risk for falling, staff are to conduct status checks. Per S3, status checks are conducted every two to three hours and consist of staff physically observing the resident to ensure they have not fallen. During the course of the investigation, LPA observed R1 being checked on by care staff on at least two occasions.

Based on record review of R1’s Individualized Service Plan and LIC624, and due to allegation being uncorroborated during interviews conducted, the Department is unable to determine if Resident sustained multiple falls while in care due to staff neglect. Although the above allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore at this time the above allegation is unsubstantiated.

An exit interview was conducted and copy of this report was provided at the end of the inspection.

SUPERVISORS NAME: Lourdes Montoya
LICENSING EVALUATOR NAME: Claudia Gutierrez
LICENSING EVALUATOR SIGNATURE:	DATE: 05/21/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/21/2026

LIC9099 (FAS) - (06/04)

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