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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 415601114
Report Date: 05/21/2026
Date Signed: 05/21/2026 01:23:16 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
04/06/2026 and conducted by Evaluator Komal Curley
PUBLIC
COMPLAINT CONTROL NUMBER: 14-AS-20260406084011
FACILITY NAME:OAKMONT OF REDWOOD CITYFACILITY NUMBER:
415601114
ADMINISTRATOR:JENNIFER DUENASFACILITY TYPE:
740
ADDRESS:1 EAST SELBY LANETELEPHONE:
(650) 885-7992
CITY:REDWOOD CITYSTATE: CAZIP CODE:
94063
CAPACITY:127CENSUS: 78DATE:
05/21/2026
UNANNOUNCEDTIME BEGAN:
10:40 AM
MET WITH:Administrator, Jennifer DuenasTIME COMPLETED:
01:35 PM
ALLEGATION(S):
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Staff did not follow physicians orders resulting in resident not receiving the correct medications
INVESTIGATION FINDINGS:
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On May 21, 2026, Licensing Program Analyst (LPA) Komal Curley conducted an unannounced complaint visit to deliver the findings for the above allegation. LPA met with Administrator, Jennifer Duenas and explained the purpose of the visit.

Regarding the allegation, staff did not follow physician's orders resulting in resident not receiving the correct medications, according to the reporting party, Resident 1 (R1) was no longer receiving Donepezil and was unsure why, was receiving an incorrect dosage of Lexapro and started receiving Olanzapine. Reporting party indicated, Donepezil should not have been discontinued in August 2025 as shown on the medication administration record (MAR) provided by the facility and Olanzapine should not have been given to R1. In addition, when R1 was admitted to the facility in July 2025, he/she was prescribed 5mg of Lexapro, the dosage increased to 10mg for Lexapro in September 2025, however does not believe the updated order was being followed.

During the visit, LPA reviewed R1's file, including but not limited to; physician's orders for medication, medication list, and MAR. (continue to 9099C)

Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: April Cowan
LICENSING EVALUATOR NAME: Komal Curley
LICENSING EVALUATOR SIGNATURE:

DATE: 05/21/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/21/2026
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 14-AS-20260406084011
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: 05/21/2026
NARRATIVE
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Based on documents reviewed, the facility received an order from Pine Park Health on 8/8/25, instructing the facility to discontinue Donepezil, start Olanzapine (2.5mg) every day, and increase dosage of Lexapro to 10mg. Based on the MAR reviewed, R1 was receiving Donepezil since admission until August 8, 2025 when Pine Park Health instructed the facility to discontinue. MAR reviewed showed Olanzapine (2.5mg) and Lexapro (10mg) was being administered as prescribed. On August 19, 2025, a new order was sent from Pine Park Health to discontinue the Olanzapine and Lexapro. LPA reviewed R1's current MAR and current prescribed medication list, centrally stored medication list was up to date.

Based on documents reviewed and information collected, 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: 05/21/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/21/2026
LIC9099 (FAS) - (06/04)
Page: 2 of 2