415601114-5-11-2026-14-AS-ACON-DU7S9Z-20260518134133

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 415601114
Report Date: 05/11/2026
Date Signed: 05/11/2026 03:23:19 PM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BRUNO RO, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066

This is an official report of an unannounced visit/investigation of a complaint received in our office on
02/18/2026 and conducted by Evaluator Komal Curley

PUBLIC

COMPLAINT CONTROL NUMBER: 14-AS-20260218102410

FACILITY NAME:	OAKMONT OF REDWOOD CITY		FACILITY NUMBER:	415601114
ADMINISTRATOR:	CAROLINE FRANGIEH		FACILITY TYPE:	740
ADDRESS:	1 EAST SELBY LANE		TELEPHONE:	(650) 885-7992
CITY:	REDWOOD CITY	STATE: CA	ZIP CODE:	94063
CAPACITY:	127	CENSUS: 76	DATE:	05/11/2026
		UNANNOUNCED	TIME BEGAN:	11:30 AM
MET WITH:	Administrator, Jennifer Duenas		TIME COMPLETED:	03:35 PM

ALLEGATION(S):

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Staff do not ensure resident's showering needs are being met
Staff do not ensure the facility is clean and sanitary
Staff do not ensure resident's laundry is being done
Staff do not ensure resident's bedding is clean
Staff are mismanaging resident's medication
Staff do not respond to resident's calls for assistance
Staff do not ensure resident's incontinence needs are being met
Staff did not provide copy of resident's admission agreement to resident's representative

INVESTIGATION FINDINGS:

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On May 11, 2026, Licensing Program Analyst (LPA) Komal Curley conducted an unannounced complaint visit to deliver the findings for the above allegations. LPA met with Administrator, Jennifer Duenas and explained the purpose of the visit.

Regarding the allegation, staff do not ensure resident's showering needs are being met, according to the reporting party, during frequent visits at the facility, it was observed that Resident 1 (R1) was not showered once.

During the investigation, LPA interviewed staff and reviewed R1's file. LPA was unable to interview R1 as R1 passed away. Based on R1's physician's report, R1 is unable to bathe himself/herself and required caregiver assistance.. According to R1's service plan dated 12/18/25, R1 required hands-on assistance for all showering/bathing needs 1-2x/week. According to R1's charting notes and staff interviewed, there were several times, R1 refused showers. (Continue to 9099C)

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: April Cowan
LICENSING EVALUATOR NAME: Komal Curley
LICENSING EVALUATOR SIGNATURE:	DATE: 05/11/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/11/2026

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 4

Control Number 14-AS-20260218102410

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BRUNO RO, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066

FACILITY NAME: OAKMONT OF REDWOOD CITY	FACILITY NUMBER: 415601114
	VISIT DATE: 05/11/2026

NARRATIVE

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Regarding the allegation, staff do not ensure the facility is clean and sanitary, according to the reporting party, staff were not taking out R1's trash and it was overflowing.

During the investigation, LPA reviewed R1's service plan and observed a random sample of rooms, including R1's room at the time. Based on observations, rooms were observed to be clean and odor-free. LPA did not observe trash on the room floors. Based on R1's service plan reviewed, R1 required no assistance beyond routine weekly housekeeping. According to staff interviewed, and R1's charting notes, R1 refused housekeeping/cleaning services.

Regarding the allegation, staff do not ensure resident's laundry is being done, according to the reporting party, it was observed R1's laundry was sitting in a pile on the floor and was not done.

During the investigation, LPA reviewed R1's file and interviewed staff. LPA was unable to interview R1 as R1 passed away. According to R1's service plan, R1 required weekly laundry service and independently manages additional laundry needs. According to staff interviewed, and R1's charting notes, R1 refused housekeeping/cleaning services.

Regarding the allegation, staff do not ensure resident's bedding is clean, according to the reporting party, it was observed that R1's bedding was soiled.

During the investigation, LPA toured and observed a random sample of rooms including R1's room at the time. and interviewed staff. LPA observed all rooms to have clean bedding. According to staff interviewed, laundry is done once a week per residency agreement, however if residents require laundry to be done more often then it would be added to their service plan. According to staff interviewed, and R1's charting notes, R1 refused housekeeping/cleaning services.

Regarding the allegation, staff are mismanaging resident's medications, according to the reporting party, on 2/10/26, R1's hospice nurse called R1's responsible party to notify him/her that R1's morphine was missing and that R1 did not receive morphine for a week.

(continue to 9099C)

SUPERVISORS NAME: April Cowan
LICENSING EVALUATOR NAME: Komal Curley
LICENSING EVALUATOR SIGNATURE:	DATE: 05/11/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/11/2026

LIC9099 (FAS) - (06/04)

Page: 2 of 4

Control Number 14-AS-20260218102410

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BRUNO RO, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066

FACILITY NAME: OAKMONT OF REDWOOD CITY	FACILITY NUMBER: 415601114
	VISIT DATE: 05/11/2026

NARRATIVE

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During the investigation, LPA reviewed R1's MAR, prescribed medication list, R1's medication destruction log and interviewed the Regional Operations Specialist. According to R1's MAR and prescribed medication list, R1 was prescribed morphine on 12/24/25 and received morphine by mouth every 2-4 hours as needed. According to documents reviewed, R1's physician ordered the facility to discontinue the administration of morphine for R1 on 1/1/26. Medication destruction log notes that the morphine was destructed on 2/26/26.

Regarding the allegation, staff do not respond to resident's calls for assistance, according to the reporting party, there were days where R1's pendant was pressed, however no staff responded.

During the investigation, LPA reviewed R1's call pendant log and interviewed residents. Based on R1's call pendant reviewed during the time R1 was a resident at the facility, the average response time was 18 minutes. According to residents interviewed, when they call for assistance, staff respond timely and help them.

Regarding the allegation, staff do not ensure resident's incontinence needs are being met, according to the reporting party, R1 was wet from his/her waist to ankles and no one changed him/her, so the hospice nurse ended up changing R1.

During the investigation, LPA reviewed R1's file and interviewed staff. LPA was unable to interview R1 as R1 passed away. Based on R1's physician's report, R1 is unable to care for his/her own toileting needs, wear depends and requires caregiver assistance. According to R1's service plan, R1 was occasionally incontinent of bladder and/or bowel and occasionally required staff assistance. According to R1's charting notes and staff interviews, there were several times, R1 refused to be changed by staff when his/her depends was soiled.

Regarding the allegation, staff did not provide copy of resident's admission agreement to resident's representative, according to the reporting party, despite providing POA documents to the facility for R1, when he/she asked for R1's admissions agreement, the Director did not provide it and stated to get it from R1.

During the investigation, LPA interviewed Regional Operations Specialist, and reviewed R1's file. (continue to 9099C)

SUPERVISORS NAME: April Cowan
LICENSING EVALUATOR NAME: Komal Curley
LICENSING EVALUATOR SIGNATURE:	DATE: 05/11/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/11/2026

LIC9099 (FAS) - (06/04)

Page: 3 of 4

Control Number 14-AS-20260218102410

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BRUNO RO, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066

FACILITY NAME: OAKMONT OF REDWOOD CITY	FACILITY NUMBER: 415601114
	VISIT DATE: 05/11/2026

NARRATIVE

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According to the Regional Operations Specialist, she denied this allegation and indicated that the individual that was asking for R1's admissions agreement did not provide any documentation to the facility to show that they were R1's responsible party or POA. In addition, based on R1's file reviewed, there were no POA documents and R1's emergency contact sheet signed on 12/3/25 did not list the individual who was requesting the admissions agreement nor did it list a medical POA. According to the Regional Operations Specialist, she provided R1 a copy of his/her admissions agreement and notified the individual that he/she can get it from R1.

Based on documents reviewed, information collected, and interviews conducted, the department has determined that although the above allegation may have happened or are valid, there is no preponderance of evidence to prove the alleged violations did or did not occur, therefore the above allegations are UNSUBSTANTIATED.

Report is reviewed with Administrator, Jennifer Duenas and a copy is provided.

SUPERVISORS NAME: April Cowan
LICENSING EVALUATOR NAME: Komal Curley
LICENSING EVALUATOR SIGNATURE:	DATE: 05/11/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/11/2026

LIC9099 (FAS) - (06/04)

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