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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 306006224
Report Date: 05/15/2026
Date Signed: 05/15/2026 11:12:07 AM

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
01/30/2023 and conducted by Evaluator Joseph Alejandre
PUBLIC
COMPLAINT CONTROL NUMBER: 22-AS-20230130171142
FACILITY NAME:OAKMONT OF FULLERTONFACILITY NUMBER:
306006224
ADMINISTRATOR:SCHROEDER, LINDSAYFACILITY TYPE:
740
ADDRESS:433 W. BASTENCHURY ROADTELEPHONE:
(805) 416-8600
CITY:FULLERTONSTATE: CAZIP CODE:
92835
CAPACITY:152CENSUS: 105DATE:
05/15/2026
UNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Maria KautenTIME COMPLETED:
11:15 AM
ALLEGATION(S):
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Facility did not seek medical attention in a timely manner.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Joseph Alejandre made an unannounced visit to deliver the findings of the complaint investigation into the allegation listed above. LPA met Executive Director Maria Kauten and explained the reason for the visit. During the course of the investigation, Department staff inspected the facility, interviewed staff, witnesses and reviewed records, including resident roster, staff roster, staff schedule, Resident 1’s (R1) physician’s report dated June 2, 2022, R1’s preplacement appraisal dated May 31, 2022, elopement risk assessment dated May 31, 2022, R1’s functional capabilities assessment, Oakmont fall management protocol, R1’s resident care notes dated November 30, 2022 to January 15, 2023, R1’s resident and services agreement dated June 3, 2022 and R1’s St. Jude Medical Records dated January 11, 2023 through January 26, 2023. The investigation into the allegation, facility did not seek medical attention in a timely manner, revealed the following.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Joseph Alejandre
LICENSING EVALUATOR SIGNATURE:

DATE: 05/15/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/15/2026
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 7
Control Number 22-AS-20230130171142
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 FULLERTON
FACILITY NUMBER: 306006224
VISIT DATE: 05/15/2026
NARRATIVE
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R1 moved into the facility on June 6, 2022. R1 was diagnosed with Hyperlipidemia, Dementia, Hyperparathyroidism, gout and had a pacemaker implant. R1 was reported to be ambulatory, could independently transfer to and from bed and did not require the use of a walker or wheelchair at the time of move in. R1 did not require assistance with most tasks. The fall risk evaluation showed R1 was a moderate fall risk and no written service plan for prevention of falls was indicated. On January 11, 2023, around 10:30 am R1 was being visited by their family. R1’s responsible party reported that R1 appeared to be in pain and observed a bruise on R1’s thigh. R1’s resident care notes dated January 8, 2023, list a bruise to R1’s thigh that may have been self-inflicted. Staff 2 (S2) reported that they noticed bruising on R1’s thigh around January 4 or January 5, 2023, and it was reported to R1’s responsible party. The name on the entry is illegible. Staff 1 (S1) reported R1 appeared fine all morning on January 11, 2023. R1’s responsible party reported that staff were unable to provide any history about the bruise on R1’s thigh. At 7:00 pm R1’s responsible party returned to the facility to visit R1. R1’s responsible party reported that staff was preparing R1 for bed and R1 was screaming. R1’s responsible party reported that that R1’s bruise was now swollen and R1 appeared to be in pain. R1’s responsible party reported that they asked Staff 1 (S1) to call 911 but S1 did not feel it was necessary to call 911 but they did so because of the request. R1 was transported to St. Jude Medical Center by ambulance. R1 was diagnosed with a distal interprosthetic fracture, a break in the femur between a hip replacement and a knee replacement. St. Jude medical records for R1 shows the attending physician noted, the fracture was of unclear chronicity (the onset cannot be precisely determined) and the injuries sustained appeared to have occurred two to three weeks earlier. R1’s responsible party reported that R1 had been unable to successfully transfer or bear weight since the beginning of January 2023. Facility staff could not corroborate this report. On January 13, 2023, R1 had surgery to repair their fracture. R1 was discharged from the hospital and moved to a skilled nursing facility for rehabilitation. R1 moved to another assisted facility after being discharged from the skilled nursing facility. R1 passed away on May 5, 2023, under hospice care. It is unknown how or when R1 sustained their fracture and the bruise on R1’s thigh was never addressed until January 11, 2023, when R1’s responsible party requested R1 be taken to the hospital. R1 was diagnosed with a distal interprosthetic fracture on January 11, 2023, and the medical records show the fracture was 2 to 3 weeks old.
SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Joseph Alejandre
LICENSING EVALUATOR SIGNATURE:

DATE: 05/15/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/15/2026
LIC9099 (FAS) - (06/04)
Page: 2 of 7
Control Number 22-AS-20230130171142
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 FULLERTON
FACILITY NUMBER: 306006224
VISIT DATE: 05/15/2026
NARRATIVE
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During the course of the investigation, the Department obtained sufficient evidence to substantiate the allegation, facility did not seek medical attention in a timely manner. See LIC9099D for cited deficiencies per Title 22 Division 6 of the California Code of Regulations. Immediate civil penalties are being assessed. See LIC421IM. A Civil Penalty is pending determination by the Community Care Licensing Division (CCLD) per Health & Safety Code section 1569.49(f). An exit interview was conducted, and a copy of this report and appeal rights were discussed with and provided to facility representative.
SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Joseph Alejandre
LICENSING EVALUATOR SIGNATURE:

DATE: 05/15/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/15/2026
LIC9099 (FAS) - (06/04)
Page: 3 of 7
Control Number 22-AS-20230130171142
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 FULLERTON
FACILITY NUMBER: 306006224
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/15/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
05/16/2026
Section Cited
CCR
87465(g)
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87465(g) The licensee shall immediately telephone 9-1-1 if an injury or other circumstance has resulted in an imminent threat to a resident’s health including, but not limited to, an apparent life-threatening medical crisis except as specified in Sections 87469(c)(2), (c)(3), or (c)(4).
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Licensee to train all care staff on CCR 87465 and to submit proof of training to LPA.
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This requirement was not met as evidenced by R1 sustained a distal interprosthetic fracture 2 to 3 weeks prior to 911 being called on January 11, 2023, at the insistence of R1’s responsible party. This poses an immediate health, safety and personal rights risk to residents 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: Sheila Santos
LICENSING EVALUATOR NAME: Joseph Alejandre
LICENSING EVALUATOR SIGNATURE:

DATE: 05/15/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/15/2026
LIC9099 (FAS) - (06/04)
Page: 4 of 7
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
01/30/2023 and conducted by Evaluator Joseph Alejandre
PUBLIC
COMPLAINT CONTROL NUMBER: 22-AS-20230130171142

FACILITY NAME:OAKMONT OF FULLERTONFACILITY NUMBER:
306006224
ADMINISTRATOR:SCHROEDER, LINDSAYFACILITY TYPE:
740
ADDRESS:433 W. BASTENCHURY ROADTELEPHONE:
(805) 416-8600
CITY:FULLERTONSTATE: CAZIP CODE:
92835
CAPACITY:152CENSUS: 105DATE:
05/15/2026
UNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Maria KautenTIME COMPLETED:
11:15 AM
ALLEGATION(S):
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2
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Due to Neglect, Resident sustained a fracture while in care.
Facility did not report an incident to resident's responsible party.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Joseph Alejandre made an unannounced visit to deliver the findings of the complaint investigation into the allegations listed above. LPA met Executive Director Maria Kauten and explained the reason for the visit. During the course of the investigation, Department staff inspected the facility, interviewed the staff, witnesses and reviewed records, including resident roster, staff roster, staff schedule, Resident 1’s (R1) physician’s report dated June 2, 2022, R1’s preplacement appraisal dated May 31, 2022, elopement risk assessment dated May 31, 2022, R1’s functional capabilities assessment, Oakmont fall management protocol, R1’s resident care notes dated November 30, 2022 to January 15, 2023, R1’s resident and services agreement dated June 3, 2022 and R1’s St. Jude Medical Records dated January 11, 2023 through January 26, 2023. The investigation into the allegation, due to neglect, resident sustained a fracture while in care, revealed the following. R1 moved into the facility on June 6, 2022. R1 was diagnosed with Hyperlipidemia, Dementia, Hyperparathyroidism, gout and had a pacemaker implanted. R1 was reported to be ambulatory, could independently transfer to and from bed and did not require the use of a walker or wheelchair at the time of move in.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Joseph Alejandre
LICENSING EVALUATOR SIGNATURE:

DATE: 05/15/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/15/2026
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 5 of 7
Control Number 22-AS-20230130171142
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 FULLERTON
FACILITY NUMBER: 306006224
VISIT DATE: 05/15/2026
NARRATIVE
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R1 did not require assistance with most tasks. The fall risk evaluation showed R1 was a moderate fall risk and no written service plan for prevention of falls was indicated. R1 suffered two reported falls while residing at the facility. The first fall occurred on September 4, 2022. R1 was walking in the hallway with their Responsible Party when they fell on their right side and they hit their face on the ground. R1 sustained a skin tear to the right eyebrow. R1 was transported to urgent care by their Responsible Party. R1 received treatment, glue strips were applied to R1’s eyebrow by Urgent Care. No other injuries were reported. On November 29, 2022, R1 had an unwitnessed fall. R1 was found in a sitting position in the dining room by their chair, no visible injuries were reported. Staff were instructed to monitor R1 for any changes. No further concerns were reported. The staff reported all falls they had knowledge of. R1 continued to ambulate with the assistance of a walker and sometimes utilized a wheelchair up until January 11, 2023, when R1 was transported to the hospital. No additional falls were reported that may have caused the bruising and fracture. It is unclear when, where or how R1 sustained their injuries which prompted R1’s hospitalization on January 11, 2023. There was nothing noted in R1’s service plan or appraisal that recommended standby assistance for walking or getting around the facility.

Based on the interviews conducted and documents reviewed, the Department is unable to ascertain if the allegation occurred as reported. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove or refute the alleged violation occurred; therefore, the allegation is deemed unsubstantiated.

The investigation into the allegation, facility did not report an incident to resident’s responsible party revealed the following. R1 resided at the facility from June 6, 2022, until January 11, 2023. R1 suffered 2 documented falls during their stay at the facility. The first fall was on September 4, 2022, and the second fall on November 29, 2022. R1’s last day at the facility was on January 11, 2022, when R1 was transported to the hospital and admitted due to their distal interprosthetic fracture, a break in the femur between a hip replacement and a knee replacement. According to hospital records the injury occurred 2 to 3 weeks prior to January 11, 2023. R1’s responsible party was present on January 11 and was notified R1 would be transported to the hospital. R1’s responsible party reported the facility reported on R1’s status regularly and should have known if R1 had an additional unwitnessed fall that caused R1’s fracture. Staff 1 (S1) reported that the bruise on R1’s thigh was reported to R1’s responsible party on January 4 or 5, 2023, R1’s responsible party did not verify this report. R1’s bruise (on the same leg as the fracture) was documented on facility records on January 8, 2023.

SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Joseph Alejandre
LICENSING EVALUATOR SIGNATURE:

DATE: 05/15/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/15/2026
LIC9099 (FAS) - (06/04)
Page: 6 of 7
Control Number 22-AS-20230130171142
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 FULLERTON
FACILITY NUMBER: 306006224
VISIT DATE: 05/15/2026
NARRATIVE
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R1’s responsible party reported they first found out about the bruise on January 11, 2023, the day R1 was transported to the hospital. It is unknown if R1 had additional unwitnessed falls. R1’s responsible party acknowledged the facility reported to them regularly regarding R1’s condition and known falls. The facility reported the falls they had knowledge of. There is no way to determine how R1 sustained their fracture. There are no records to show that R1 was found on the floor or displayed behaviors in January prior to January 11, 2023, that would lead the facility to suspect R1 had suffered an unwitnessed fall, except for the bruise on R1’s thigh. Facility staff reported R1’s responsible party was notified about the bruise. The facility cannot be expected to report an incident they have no knowledge of.

Based on the interviews conducted and documents reviewed, the Department is unable to ascertain if the allegation occurred as reported. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove or refute the alleged violation occurred; therefore, the allegation is deemed unsubstantiated.

SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Joseph Alejandre
LICENSING EVALUATOR SIGNATURE:

DATE: 05/15/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/15/2026
LIC9099 (FAS) - (06/04)
Page: 7 of 7