392701272-4-27-2026-27-AS-LKIG-DTZT36-20260512142149

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 392701272
Report Date: 04/27/2026
Date Signed: 04/27/2026 03:52:11 PM

Substantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

This is an official report of an unannounced visit/investigation of a complaint received in our office on
12/04/2025 and conducted by Evaluator Arielle Pascua

PUBLIC

COMPLAINT CONTROL NUMBER: 27-AS-20251204140501

FACILITY NAME:	OAKMONT OF LODI		FACILITY NUMBER:	392701272
ADMINISTRATOR:	ARMSTRONG, ANDREA		FACILITY TYPE:	740
ADDRESS:	2905 REYNOLDS RANCH PARKWAY		TELEPHONE:	(209) 310-1512
CITY:	LODI	STATE: CA	ZIP CODE:	95240
CAPACITY:	136	CENSUS: 86	DATE:	04/27/2026
		UNANNOUNCED	TIME BEGAN:	12:15 PM
MET WITH:	Andrea Armstrong		TIME COMPLETED:	12:45 PM

ALLEGATION(S):

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Staff did not provide adequate supervision to resident in care resulting in the resident leaving the facility unassisted
Facility staff charged fees to the resident's authorized representative for services not listed in the admission agreement

INVESTIGATION FINDINGS:

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Unannounced complaint visit made out to this facility on 03/30/2026 by Licensing Program Analyst (LPA) Arielle Pascua who was met by the facility designated Administrator, Andrea Armstrong, who was briefly interviewed at this time.
Current census was 86 residents.
The purpose of this visit was to inform this facility, and its designated representative, that the investigation had been completed and present the findings at this time.
Based on interviews conducted, it was learned that R1 had eloped from this facility on 12/02/2025 during the early morning hours. It was learned that R1 had removed the window screen from R1’s bedroom window and climbed out. It was learned that R1 was diagnosed with dementia and was placed in the memory care unit, Traditions, at this facility. This memory care unit was equipped with delayed egress and alarms on all exits including the windows in the residents’ bedrooms designed to notify facility staff if any exits were used by any residents attempting to leave the premises.

Substantiated

Estimated Days of Completion:

SUPERVISORS NAME: Lisa Rios
LICENSING EVALUATOR NAME: Arielle Pascua
LICENSING EVALUATOR SIGNATURE:	DATE: 04/27/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/27/2026

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 27-AS-20251204140501

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: OAKMONT OF LODI	FACILITY NUMBER: 392701272
	VISIT DATE: 04/27/2026

NARRATIVE

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Based on an interview with the facility designated Administrator, Andrea Armstrong, she admitted that the alarm for the window did not activate when R1 kicked out the window screen like it was designed to do which allowed R1 to climb out of R1’s bedroom window on 12/02/2025. It was learned that there were sensors placed on the windows and the screens so that if any of them were triggered then the system would have activated and facility personnel would have gotten the alerts.
It was learned that if this alarm had triggered like it was designed to do then the system would have notified the facility staff to respond and would have possibly prevented the elopement of R1. It was learned that this facility did not have a definite timeline of when R1 eloped from this facility and had to involve local law enforcement, facility staff, and family/friends before R1 was found and brought back to this facility. It was learned that R1 had been gone from this facility for over 8 hours before she was returned safely back to this facility.
It was learned that a similar incident of elopement for R1 took place on 11/29/2025 where R1 was able to exit the memory care unit and was later found in the Assisted Living portion of this facility. It was unknown to the facility staff and responsible parties for R1 as to how R1 was able to leave the secured perimeter of the memory care unit when it was equipped with a keypad before exiting and how the alarms were not triggered at that time.
Based on a review of the forms and documents gathered during this investigation, it was learned that R1 moved into this facility on 10/31/2025 and had an initial assessment performed by this facility on 11/07/2025. A review of the Individualized Service Plan was conducted for R1 at this time.
It was learned that a second assessment was conducted and completed on 12/05/2025 after the elopement incident which took place on 12/02/2025. It was observed that there weren’t any major changes noted on the updated assessment except for language addressing the risk for elopement and the staff’s responsibility to perform checks on R1 to redirect/reorient R1 when it was observed that R1 was gravitating towards facility exits. It was learned that all other areas regarding behaviors, Activities of Daily Living (ADLs), and Special Medical Needs were unchanged at this time. It was learned that R1 did not exhibit any behaviors which were a threat to R1 nor a threat to any other residents in care.

SUPERVISORS NAME: Lisa Rios
LICENSING EVALUATOR NAME: Arielle Pascua
LICENSING EVALUATOR SIGNATURE:	DATE: 04/27/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/27/2026

LIC9099 (FAS) - (06/04)

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Control Number 27-AS-20251204140501

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: OAKMONT OF LODI	FACILITY NUMBER: 392701272
	VISIT DATE: 04/27/2026

NARRATIVE

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Based on a review of the forms and documents gathered during this investigation, it was learned that One on One Supervision for Emergency Situations was an additional item and service that was elected by the resident, and their responsible parties, upon admission to this facility. It was learned that this item and service was not elected upon admission for R1. It was learned that this One-on-One service was implemented by this facility after the elopement incident for R1.
It was learned that the One-on-One Care or Supervision could only be implemented if a resident was deemed to be a danger to themselves or others. Based on the updated assessment completed on 12/05/2025 R1 was never deemed to be a threat to themself or to others.

As a result of this investigation, this LPA found the allegations to be SUBSTANTIATED - A finding that the complaint was Substantiated meant that the allegation was valid because the preponderance of the evidence standard had been met.

The following deficiencies were observed and cited on the following LIC 9099-D pursuant to Title 22 Rules and Regulations, Division 6 and Health and Safety Codes.

Appeal rights were printed and a copy was left with the facility designated Administrator at this time.

Exit Interview

SUPERVISORS NAME: Lisa Rios
LICENSING EVALUATOR NAME: Arielle Pascua
LICENSING EVALUATOR SIGNATURE:	DATE: 04/27/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/27/2026

LIC9099 (FAS) - (06/04)

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Control Number 27-AS-20251204140501

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: OAKMONT OF LODI	FACILITY NUMBER: 392701272
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 04/27/2026

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 04/28/2026 Section Cited CCR 87411(a)	1 2 3 4 5 6 7	(a) Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs. This is not met as evidenced by:	1 2 3 4 5 6 7	An immediate civil penalty of $500 was issued for violation of this Section. The facility administrator stated that elopement training was conducted in December 2025.
	8 9 10 11 12 13 14	Based on interviews and record review. The Licensee did not ensure adequate supervision of residents in care. R1 was able to exit from their bedroom. This poses an immediate health and safety risk to the R1 in care.	8 9 10 11 12 13 14	A statement of correction and acknowledgement along with documented proof of scheduled training topics, dates, and times will be completed and submitted into CCL by the due date.
Type B 05/11/2026 Section Cited HSC 1569.957(a)	1 2 3 4 5 6 7	(a) For any rate increase due to a change in the level of care of the resident, the licensee shall provide the resident and the resident’s representative, if any, written notice of the rate increase within two business days after initially providing services at the new level of care. The notice shall include a detailed explanation of the additional services to be provided at the new level of care and an accompanying itemization of the charges.	1 2 3 4 5 6 7	The facility shall provide this LPA a statement of correction highlighting the facilities policies and procedures regarding rate increases and admission policies by POC date.
	8 9 10 11 12 13 14	This is not met as evidenced by: Based on interview and record review, the licensee did not ensure that the resident's responsible representive was provided a notice of a rate increase based on their level of care. This poses a potential health, safety, and personal rigths risks to persons in care.	8 9 10 11 12 13 14

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: Lisa Rios
LICENSING EVALUATOR NAME: Arielle Pascua
LICENSING EVALUATOR SIGNATURE:	DATE: 04/27/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/27/2026

LIC9099 (FAS) - (06/04)

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