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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 306005740
Report Date: 05/28/2026
Date Signed: 05/28/2026 03:42:23 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
06/25/2024 and conducted by Evaluator Jessica Cho
PUBLIC
COMPLAINT CONTROL NUMBER: 22-AS-20240625085618
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:
05/28/2026
UNANNOUNCEDTIME BEGAN:
08:00 AM
MET WITH:Angela Boyd- Health Services DirectorTIME COMPLETED:
04:00 PM
ALLEGATION(S):
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Facility staff did not assist resident with incontinence care as needed.
Facility staff did not assist resident with showering as needed.
Facility staff handled the resident in a rough manner.
INVESTIGATION FINDINGS:
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On May 28, 2026, Licensing Program Analyst (LPA) Jessica Cho made an unannounced visit for the purpose of concluding the investigation into the above allegations. LPA met with Health Services Director (HSD) Angela Boyd and stated the reason for the visit. During the course of the investigation, the Department toured the facility, interviewed eight residents, three staff, and obtained documentation for review: Resident Rosters, Personnel Rosters, Face Sheets, Physician's Reports, Individualized Service Plans, and Resident Care Notes.

The investigation is as follows: On June 25, 2024, the Department received the complaint. The investigation was initiated by LPA Jenifer Tirre on July 3, 2024. LPA Tirre toured the physical plant of the facility including resident rooms. LPA Cho continued the investigation on today's date, conducted interviews, and review of records. Regarding the allegation, Facility staff did not assist resident with incontinence care as needed, it is alleged that Resident #1 (R1) would lie soiled in feces or urine.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Lourdes Montoya
LICENSING EVALUATOR NAME: Jessica Cho
LICENSING EVALUATOR SIGNATURE:

DATE: 05/28/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/28/2026
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 2
Control Number 22-AS-20240625085618
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: 05/28/2026
NARRATIVE
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Based on the review of R1's service plan dated June 19, 2024, R1 was provided complete assistance with toileting according to schedule, needs, and requests. Based on the review of R1's care notes, there were written documentation providing brief changes on May 12, 13, 30, 31, 2024, and during the nocturnal shifts. R1 also refused to use the toilet and requested brief changes in bed on May 30, 2024. Based on an interview with a witness, R1 alleged "waiting for hours" when staff was called for assistance. Care notes reveal that R1 was checked on "multiple times throughout shifts" even though R1 "voiced complaints of staff not checking in overnight." Based on the interviews with eight residents who resided at the facility in 2024, none of the residents are incontinent. Three of eight residents required assistance with toileting which also aligned with their care plans at the time; however two of three residents that required toileting, confirmed toileting assistance was provided as needed per their requests. LPA was unable to qualify the statement of the third resident due to their medical condition, and two of three staff denied the allegation while the third indicated not providing care to R1 at the time.

Regarding the allegation, Facility staff did not assist resident with showering as needed, it is alleged that R1 received sporadic showers. Based on the review of R1's service plan, complete assistance with showering/bathing was provided four times a week for R1. There were no documentation regarding showers per the care notes. However, based on the interviews with eight residents who resided at the facility in 2024, seven confirmed showers were provided timely which aligned with their individual plans. LPA was unable to qualify one resident due to their medical condition. Two of three staff denied the allegation while the third staff indicated not providing care to R1 at the time.

Regarding the allegation, Facility staff handled the resident in a rough manner, it is alleged that the handling of R1 was "roughed up." Based on the interviews, seven of eight residents who resided at the facility in 2024 denied experiencing aggressive handling also denied by two of three staff who were employed at the time. However, one resident confirmed one caregiver was rough in the way they assisted them during transfers. The remaining one staff did not provide care to R1 at the time.

Based on interviews and record review, although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore, all allegations are deemed UNSUBSTANTIATED. An exit interview was conducted with Health Services Director Angela Boyd, and a copy of this report was provided at the end of the visit.
SUPERVISORS NAME: Lourdes Montoya
LICENSING EVALUATOR NAME: Jessica Cho
LICENSING EVALUATOR SIGNATURE:

DATE: 05/28/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/28/2026
LIC9099 (FAS) - (06/04)
Page: 2 of 2