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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 415601114
Report Date: 07/10/2025
Date Signed: 07/10/2025 12:59:13 PM

Substantiated


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
01/13/2025 and conducted by Evaluator Komal Charitra
PUBLIC
COMPLAINT CONTROL NUMBER: 14-AS-20250113154240
FACILITY NAME:OAKMONT OF REDWOOD CITYFACILITY NUMBER:
415601114
ADMINISTRATOR:SIOBHAN SURRACOFACILITY TYPE:
740
ADDRESS:1 EAST SELBY LANETELEPHONE:
(650) 885-7992
CITY:REDWOOD CITYSTATE: CAZIP CODE:
94063
CAPACITY:127CENSUS: 64DATE:
07/10/2025
UNANNOUNCEDTIME BEGAN:
11:33 AM
MET WITH:Interim Executive Director, Kathleen OlsonTIME COMPLETED:
01:10 PM
ALLEGATION(S):
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Resident sustained unexplained fracture while in care.
INVESTIGATION FINDINGS:
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On July 10, 2025, Licensing Program Analyst (LPA) Komal Charitra conducted an unannounced complaint visit to deliver the findings for the above allegation. LPA met with Interim Executive Director, Kathleen Olson and explained the purpose of the visit.

Regarding the allegation, resident sustained unexplained fracture while in care, according to the reporting party, on 10/13/24, it was observed the Resident 1 (R1) was in distress, complaining of pain in his/her groin area. In addition, the reporting party indicated, after transporting R1 to the hospital, various tests and an X-ray revealed a fracture on the left side of his/her pelvis. The reporting party reported that the staff at the facility did not know how or when the fracture occurred.

During the investigation, the Department reviewed R1's file, interviewed staff and reviewed R1's medical records. According to R1's file reviewed, R1 was evaluated at low risk for falling, however staff interviewed thought R1 had fallen at an earlier date but were not able to provide details and there was no documentation of a fall. (continue to 9099C)
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: April Cowan
LICENSING EVALUATOR NAME: Komal Charitra
LICENSING EVALUATOR SIGNATURE:

DATE: 07/10/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/10/2025
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 5
Control Number 14-AS-20250113154240
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: 07/10/2025
NARRATIVE
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 In addition, staff interviewed had conflicting information on whether R1 was a fall risk or not. Facility staff were unaware of R1's injuries and did not document or notice any changes in condition nor how the injury could have been sustained. Based on medical records, on 10/13/24, R1 was transported to the hospital and three x-ray views of R1's left hip did not show any fracture at the time. Further evaluation with cross-sectional imagining was recommended and conducted on 10/16/24 where a computed tomography (CT) scan was conduct of his/her left hip for a possible fall. Medical documentation indicated that the CT scan showed that R1 had an acute non-displaced fracture through the base of the left superior pubic ramus and through the mid left inferior pubic ramus.

Based on the investigation, the preponderance of evidence standard has been met, therefore the above allegation is found to be substantiated. Deficiencies of the California Code of Regulations, Title, 22 cited on the LIC9099-D. Failure to correct the deficiencies may result in civil penalties. Failure to correct said deficiencies may result in additional civil penalties.

AN IMMEDIATE CIVIL PENALTY OF $500.00 WAS ASSESSED TODAY: $500 FOR THE VIOLATION AS R1 SUSTAINED UNEXPLAINED FRACTURE WHILE IN CARE.

A repeat civil penalty of $500 was issued today due to the same violation being cited on 5/27/25.

Due to immediate civil penatly of $500 being cited and repeat civil penalty of $500 being cited, total civil penalty being issued today is $1,000

THE INTERIM EXECUTIVE DIRECTOR WAS INFORMED THAT AN ADDITIONAL CIVIL PENALTY IS STILL BEING DETERMINED AND MIGHT BE ASSESSED BASED ON HEALTH AND SAFETY CODE §1569.49.

Report is reviewed with the Interim Executive Director and a copy is provided with appeal rights.
SUPERVISORS NAME: April Cowan
LICENSING EVALUATOR NAME: Komal Charitra
LICENSING EVALUATOR SIGNATURE:

DATE: 07/10/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/10/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 5
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
01/13/2025 and conducted by Evaluator Komal Charitra
PUBLIC
COMPLAINT CONTROL NUMBER: 14-AS-20250113154240

FACILITY NAME:OAKMONT OF REDWOOD CITYFACILITY NUMBER:
415601114
ADMINISTRATOR:SIOBHAN SURRACOFACILITY TYPE:
740
ADDRESS:1 EAST SELBY LANETELEPHONE:
(650) 885-7992
CITY:REDWOOD CITYSTATE: CAZIP CODE:
94063
CAPACITY:127CENSUS: 64DATE:
07/10/2025
UNANNOUNCEDTIME BEGAN:
11:33 AM
MET WITH:Interim Executive Director, Kathleen OlsonTIME COMPLETED:
01:10 PM
ALLEGATION(S):
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Facility staff did not seek medical attention in a timely manner.
Facility staff are not cleaning resident's room.
Facility staff did not communicate with authorized representative(s) on resident changes in health condition.
INVESTIGATION FINDINGS:
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On July 10, 2025, Licensing Program Analyst (LPA) Komal Charitra conducted an unannounced complaint visit to deliver the findings for the above allegations. LPA met with Interim Executive Director, Kathleen Olson and explained the purpose of the visit.

Regarding the allegation, facility staff did not seek medical attention in a timely manner, according to the reporting party, on 10/13/24, it was observed the Resident 1 (R1) was in distress, complaining of pain in his/her groin area, was unable to stand up and was shivering. In addition, according to the reporting party, R1 was complaining of pain for three days before being sent to the hospital on 10/13/24.

During the investigation, the Department interviewed staff and reviewed documents. Based on medical records reviewed, R1 was sent to the hospital on 10/13/24 after complaining of pain for three days. According to staff interviewed, staff were not aware why R1 was sent to the hospital on 10/13/24 as staff reported not seeing R1 fall or hearing of R1 falling on or before 10/13/24. In addition, according to staff interviews, they did not observe any changes in R1’s condition or being aware of R1 complaining of pain prior to being sent to the hospital on 10/13/24. (continue to 9099C)
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: April Cowan
LICENSING EVALUATOR NAME: Komal Charitra
LICENSING EVALUATOR SIGNATURE:

DATE: 07/10/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/10/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 3 of 5
Control Number 14-AS-20250113154240
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: 07/10/2025
NARRATIVE
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Regarding the allegation, facility staff are not cleaning resident's room, according to the reporting party, on 10/13/24, it was observed that R1's room was filthy, with soiled bed linens, old, soiled clothing, and urine pads on the floor.

During the investigation, LPA toured the facility and observed a random sample of eight resident rooms including R1's room. Based on observations, rooms toured were observed to be clean, odor-free, and with clean bed linens. During the visit, LPA was notified that R1 was no longer a resident at the facility. According to staff interviewed, there are two housekeepers on shift in the AM and two housekeepers in the PM. Housekeepers are deep cleaning rooms every week, taking out trash from resident's room per shift and doing laundry as needed. In addition, staff interviewed indicated that every shift change, caregivers will check each resident rooms to make beds and collect trash at the beginning and at the end of each shift.

Regarding the allegation, facility staff did not communicate with authorized representative(s) on resident changes in health condition, according to the reporting party, the facility staff did not know how or when R1 suffered a fracture and did not notify R1's authorized representative of any injuries or changes in condition.

During the investigation, staff were interviewed and R1's charting notes were reviewed. Based on charting notes, there was no notes that indicated R1 had a fall or a change of condition. According to staff interviewed, they were unaware why R1 was sent to the hospital on 10/13/24 and indicated they did not see or here about R1 having a fall before or on 10/13/24. Additionally staff interviewed also indicated that they did not observe any changes in R1's condition or R1 complaining of pain prior to being sent to the hospital.

Based on interviews conducted, interviews conducted and documents reviewed, the department has determined that although the above allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegation is UNSUBSTANTIATED. Report is reviewed with Interim Executive Director and a copy is provided.
SUPERVISORS NAME: April Cowan
LICENSING EVALUATOR NAME: Komal Charitra
LICENSING EVALUATOR SIGNATURE:

DATE: 07/10/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/10/2025
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 14-AS-20250113154240
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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/10/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Deficiency Dismissed
Type A
07/11/2025
Section Cited
CCR
87464(f)(1)
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87464 Basic Services: (f) Basic services shall at a minimum include: (1) Care and supervision as defined in Section 87101(c)(3) and Health and Safety Code
section 1569.2(c).

This requirement is not met as evidenced by:
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Licensee/administrator shall conduct an in-service training regarding fall risk and ensuring changes in resident's condition are documented. In addition, training shall also include, fall prevention planning when residents are at low to high fall risk.
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Based on interviews and medical records, on 10/16/24 a CT scan was conducted for R1 on his/her left hip for a possible fall. Medical documentation indicated that the CT scan showed that R1 had an acute non-displaced fracture through the base of the left superior pubic ramus and through the mid left inferior pubic ramus which poses an immediate health and safety risk for residents in care.
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Civil penalty in the amount of $500.00 is being assessed today as Resident 1 (R1) sustained unexplained fracture while in care.

A repeat civil penalty of $500 was issued today due to the same violation being cited on 5/27/25.

Due to immediate civil penatly of $500 being cited and repeat civil penalty of $500 being cited, total civil penalty being issued today is $1000.00
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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: April Cowan
LICENSING EVALUATOR NAME: Komal Charitra
LICENSING EVALUATOR SIGNATURE:

DATE: 07/10/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/10/2025
LIC9099 (FAS) - (06/04)
Page: 5 of 5