374604533-3-25-2026-08-AS-SJAB-DVLVJ2-20260702162758

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 374604533
Report Date: 03/25/2026
Date Signed: 03/25/2026 08:26:51 AM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN DIEGO RO, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108

This is an official report of an unannounced visit/investigation of a complaint received in our office on
07/25/2025 and conducted by Evaluator Rebecca A Borunda

COMPLAINT CONTROL NUMBER: 08-AS-20250725154638

FACILITY NAME:	SANTIANNA OAKMONT SIGNATURE LIVING		FACILITY NUMBER:	374604533
ADMINISTRATOR:	SAMPEDRO, TAMMIE		FACILITY TYPE:	740
ADDRESS:	2560 FARADAY AVE		TELEPHONE:	(442) 325-8090
CITY:	CARLSBAD	STATE: CA	ZIP CODE:	92010
CAPACITY:	0	CENSUS: 0	DATE:	03/25/2026
		UNANNOUNCED	TIME BEGAN:	08:15 AM
MET WITH:	N/A		TIME COMPLETED:	08:20 AM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Questionable Death
Staff did not seek medical attention for a resident in care
Staff did not prevent resident(s) from eloping from the facility
Staff did not meet resident's care needs

INVESTIGATION FINDINGS:

1
2
3
4
5
6
7
8
9
10
11
12
13

The following determination of findings has been made by Licensing Program Analyst (LPA) Rebecca Borunda regarding the above-mentioned allegations. The facility closed on 11/26/2025, due to change of ownership, and this report was mailed to the last known address on record for the former Licensee regarding the findings.

The Department’s investigation consisted of interviews with staff, and outside sources, records review, and a tour of the facility. It was alleged that Resident 1’s death was questionable and staff did not seek medical attention for a resident in care. Review of incident reports submitted to the Department in July 2025 and charting notes for R1 revealed that on 7/4/2025, R1 was observed to have a change in condition, resulting in a loss of consciousness. Staff called 911 and performed cardiopulmonary resuscitation (CPR) on R1 while waiting for emergency personnel.

Continued on LIC9099-C page...

Unsubstantiated

Estimated Days of Completion: 0

SUPERVISORS NAME: Sabel Martinez
LICENSING EVALUATOR NAME: Rebecca A Borunda
LICENSING EVALUATOR SIGNATURE:	DATE: 03/25/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/25/2026

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 08-AS-20250725154638

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN DIEGO RO, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108

FACILITY NAME: SANTIANNA OAKMONT SIGNATURE LIVING	FACILITY NUMBER: 374604533
	VISIT DATE: 03/25/2026

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

R1 was transported to the hospital and was diagnosed with vasovagal syncope. Upon returning to the facility on the same day, R1 was placed on increased safety checks. In the evening of 7/18/2025, R1 had an unwitnessed fall in a common area and was assessed by staff for injuries and pain. R1 sustained a minor injury that required basic first aid and staff notified R1’s responsible party and physician. Approximately 5 hours later, R1 was found to be unresponsive with no pulse beside their bed. Staff started CPR, called 911, and law enforcement and paramedics responded to the facility. R1 was declared deceased by law enforcement on 7/18/2025. Review of R1’s death certificate revealed that their cause of death was congestive heart failure and Parkinson’s Disease, with onsets of years. R1’s death certificate did not include any evidence that R1’s falls in July 2025 were noted to have caused or contributed to R1’s death. Interviews with staff did not reveal any evidence that staff did not attempt to obtain or delayed appropriate medical care for R1 following their falls.

It was alleged that staff did not prevent residents from eloping from the facility, specifically Resident 2 (R2) and Resident 3 (R3) and that staff were not meeting the needs of a resident in care. Review of assessment records for R2 revealed that R2 was ambulatory and had a diagnosis of mild cognitive impairment (MCI). However, R2 was noted to not be confused or disoriented and was able to follow directions, manage their own cash resources, and leave the facility unassisted. Additionally, R2 was described as very active, healthy, and social, with no mention of any behaviors that would have required increased supervision or limits to be placed on R2’s ability to leave the facility unassisted. Review of R3’s assessment records revealed that R3 was diagnosed with MCI, was confused and disoriented, but was able to follow instructions, communicate needs, and able to leave the facility unassisted with friends and relatives. Review of the incident reports submitted to the Department by the facility between May and July 2025 did not reveal any report elopement of residents, including R2 or R3. Information collected during staff interviews did not support any evidence that residents, including R2 or R3, had eloped from the facility. Additionally, interviews with staff working at the facility in 2025 did not provide any relevant information on the supervision and care needs of R2 or R3. Interviews did not reveal any concerns that residents did not receive the care and supervision appropriate to their care levels.

The Department has investigated the above-mentioned allegations and based on interviews and records review, the preponderance of the evidence has not been met, therefore, this allegation is deemed unsubstantiated. A copy of this report and the Licensee Appeal Rights (LIC9058 03/22) were mailed to the last known address on file for the Licensee.

SUPERVISORS NAME: Sabel Martinez
LICENSING EVALUATOR NAME: Rebecca A Borunda
LICENSING EVALUATOR SIGNATURE:	DATE: 03/25/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/25/2026

LIC9099 (FAS) - (06/04)

Page: 2 of 2