315002955-3-18-2026-59-AS-TORZ-DSGP9Q-20260324110731

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 315002955
Report Date: 03/18/2026
Date Signed: 03/18/2026 10:59:40 AM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 2525 NATOMAS PARK DR STE 270
SACRAMENTO, CA 95833

This is an official report of an unannounced visit/investigation of a complaint received in our office on
01/27/2026 and conducted by Evaluator Bethany Mirlohi

COMPLAINT CONTROL NUMBER: 59-AS-20260127102741

FACILITY NAME:	OAKMONT OF WESTPARK		FACILITY NUMBER:	315002955
ADMINISTRATOR:	FLECK, BARBARA		FACILITY TYPE:	740
ADDRESS:	2400 PLEASANT GROVE BLVD.		TELEPHONE:	(916) 545-8904
CITY:	ROSEVILLE	STATE: CA	ZIP CODE:	95747
CAPACITY:	142	CENSUS: 91	DATE:	03/18/2026
		UNANNOUNCED	TIME BEGAN:	10:40 AM
MET WITH:	Lisa Velasco, Health Services Director		TIME COMPLETED:	11:30 AM

ALLEGATION(S):

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Staff left resident in soiled briefs for extended period of time
Staff did not report incidents to responsible party

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Bethany Mirlohi arrived unannounced to deliver complaint investigation findings. LPA met with Lisa Velasco during today’s inspection.
LPA investigated allegation, “Staff left resident in soiled briefs for extended period of time”. During the complaint investigation LPA reviewed resident documentation, hospice documentation, conducted a tour, and interviewed staff. On 1/29/26 LPA toured the memory care unit and observed residents engaged in an activity while others were still eating in the dining room. LPA observed residents looked well groomed and comfortable. During the tour LPA observed no foul odor and residents rooms appeared clean and organized. LPA reviewed R1’s hospice documentation and observed one occasion resident was found to be soiled however LPA was unable to determine for how long. LPA reviewed R1’s facility documentation and found resident required continence care but no issues were documented.

Continuation on 9099-C.

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Troy Ordonez
LICENSING EVALUATOR NAME: Bethany Mirlohi
LICENSING EVALUATOR SIGNATURE:	DATE: 03/18/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/18/2026

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 59-AS-20260127102741

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 2525 NATOMAS PARK DR STE 270
SACRAMENTO, CA 95833

FACILITY NAME: OAKMONT OF WESTPARK	FACILITY NUMBER: 315002955
	VISIT DATE: 03/18/2026

NARRATIVE

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LPA interviewed relevant party in which they stated they observed R1 saturated with urine several times. LPA interviewed 4 care staff who helped R1 with care, and they stated they changed R1 every 2 hours or as needed. No care staff reported issues with R1’s continence care. Due to the information gathered LPA finds allegation to be Unsubstantiated.

LPA investigated allegation, “Staff did not report incidents to responsible party”. LPA reviewed hospice and facility information and interviewed relevant party and staff. LPA reviewed hospice documentation and observed there were no concerns with facilities reporting. LPA reviewed facility documentation, in which staff documented several incidents and each time it was documented that family and hospice were notified. LPA interviewed relevant party in which they stated there were several times that facility did not report to R1’s family concerning incidents and only found out through hospice. LPA interviewed 4 care staff in which they stated whenever something occurred with R1 they would report the issue to the family and hospice immediately. Care staff had no concerns with reporting incidents to families. Due to the information gathered LPA finds allegation to be unsubstantiated.

Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove that the alleged violations occurred, and the findings are unsubstantiated. Exit interview was conducted.

SUPERVISORS NAME: Troy Ordonez
LICENSING EVALUATOR NAME: Bethany Mirlohi
LICENSING EVALUATOR SIGNATURE:	DATE: 03/18/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/18/2026

LIC9099 (FAS) - (06/04)

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