435202772-7-18-2025-26-AS-MPAA-DKEQ62-20250810115247

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 435202772
Report Date: 07/18/2025
Date Signed: 07/18/2025 03:31:23 PM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CENTRAL COAST CR/RES, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131

This is an official report of an unannounced visit/investigation of a complaint received in our office on
01/03/2023 and conducted by Evaluator David Marrufo

COMPLAINT CONTROL NUMBER: 26-AS-20230103165022

FACILITY NAME:	OAKMONT OF SILVER CREEK		FACILITY NUMBER:	435202772
ADMINISTRATOR:	BAGHERI, TAYEBEH		FACILITY TYPE:	740
ADDRESS:	3544 SAN FELIPE ROAD		TELEPHONE:	(669) 288-5000
CITY:	SAN JOSE	STATE: CA	ZIP CODE:	95135
CAPACITY:	0	CENSUS: 0	DATE:	07/18/2025
		UNANNOUNCED	TIME BEGAN:	01:45 PM
MET WITH:	Minnie Weber		TIME COMPLETED:	03:45 PM

ALLEGATION(S):

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Illegal eviction.
Facility did not provide written incident reports to resident's responsible person.

INVESTIGATION FINDINGS:

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LPA Marrufo conducted an unannounced complaint investigation visit and met with Executive Director Minnie Weber. On 01/03/2023, the Department received a complaint with the above allegations. On 01/11/2023, the department conducted an initial complaint investigation visit. On 06/01/2023, the department conducted an additional complaint investigation visit.

Resident R1’s Preplacement Appraisal Information Form was signed by R1’s Representative on 09/15/2022. The form’s Mental Condition section states, “Delusional and Hallucinations.” The form’s Health History section states, “Hospitalizations - …hallucinations, 5150 holds – in 2021 and 2022.”

R1’s Admission Agreement was signed by R1’s Representative and has an effective date of 09/16/2022.
R1’s Physician’s Report is dated 09/16/2022 and has an exam date of 09/16/2022. R1’s Physician’s Report states R1’s Primary Diagnosis is dementia with psychotic behavior.
See LIC9099-C page for more information. Page 1 of 4.

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Maria Partoza
LICENSING EVALUATOR NAME: David Marrufo
LICENSING EVALUATOR SIGNATURE:	DATE: 07/18/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/18/2025

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 4

Control Number 26-AS-20230103165022

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CENTRAL COAST CR/RES, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131

FACILITY NAME: OAKMONT OF SILVER CREEK	FACILITY NUMBER: 435202772
	VISIT DATE: 07/18/2025

NARRATIVE

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R1’s Individualized Service Plan has a service plan date of 09/22/2022. R1’s Individualized Service Plan states in the Delusions and Hallucinations section, “Resident experiences pleasant or non-threatening hallucinations or delusions that do not require staff intervention. Receives observations and assistance when experiencing hallucinations and/or delusions. Observe behaviors and guide as needed. Provide assistance and supportive environment.”

The Destructive section states, “Resident gently moves items throughout the common areas such as furniture and skill station objects. But no additional staff time is needed to intervene. Receives observation and assistance when displaying behavior destructive to items in common areas. Observe behaviors and guide as needed. Provide assistance and supportive environment.”

The Combative section states, “Resident has combative episodes (hitting, biting, scratching, throwing things). Receives monitoring and assistance when displaying combative behaviors. Assess resident’s ability to remain in current environment.”

R1’s Assessment Form has an assessment date of 09/15/2022. R1’s Assessment Form provides the following scores: Delusions and Hallucinations: 0; Destructive: 0; Combative: 18; Exit Seeking: left blank. R1’s Assessment Form has no signature from either the Evaluator or Family Member.

R1’s Resident Assessment has an effective date of 12/27/2022. R1’s Resident Assessments provides the following scores: Delusions and Hallucinations: 14, Destructive: 18, Combative: 18, Exit Seeking: 21. R1’s Resident Assessment was signed by R1’s Representative and a Reviewer on 12/28/2022.

R1’s Behavioral Intervention Record includes entries from 09/17/2022 to 12/25/2022. R1’s Behavioral Intervention Record records the following behaviors: “Combative x tried to slap care staff”, “throwing things, yelling”, “yelling, screaming, + throwing things”, “scratching and hitting care staff”, “hitting and throwing and screaming”, “grabbing resident’s collar and tried hitting”, “Threw coffee on the floor”, “hit cup, it cracked + coffee spilt on floor & table” and “Screaming/angry hitting.”

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SUPERVISORS NAME: Maria Partoza
LICENSING EVALUATOR NAME: David Marrufo
LICENSING EVALUATOR SIGNATURE:	DATE: 07/18/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/18/2025

LIC9099 (FAS) - (06/04)

Page: 2 of 4

Control Number 26-AS-20230103165022

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CENTRAL COAST CR/RES, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131

FACILITY NAME: OAKMONT OF SILVER CREEK	FACILITY NUMBER: 435202772
	VISIT DATE: 07/18/2025

NARRATIVE

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R1’s Prescription Order from 12/14/2022 states, “Drug Diagnosis: Source 1, Description Unspecified schizophrenia spectrum and other psychotic disorder.”

R1’s 30-day Eviction Notice is dated 12/28/2022 and was sent to R1’s Responsible Person. The Eviction Notice states, “When [R1] moved into our memory care unit on September 17, 2022, the diagnosis provided was dementia with psychosis….Unfortunately, [R1] began to exhibit symptoms more related to a mental illness as opposed to the typical dementia symptoms our community is equipped to handle. [R1] was fixating on [his/her] narcotic medications, and [he/she] began exhibiting aggressive behavior to the staff and other residents. Despite numerous medication changes and consultations with [his/her] psychiatrist, the behavior continued. On 12-14 a new diagnosis of Schizophrenia was provided which is outside the scope of our programs to manage.”

R1’s Eviction Notice provided the following examples of R1’s behaviors: On 11/23/2022, R1 yelled at a resident and threw a coffee cup at the resident and a staff. On 11/27/2022, a resident stated R1 hit him/her and staff observed the resident with a cut on his/her head and a swollen left eye. On 12/05/2022, R1 slapped a staff in the face. On 12/13/2022, R1 yelled at a staff and grabbed the staff by the collar. On 12/26/2022, R1 hit a staff four times in the face and pulled the staff’s hair.

LPA Marrufo obtained copes of Unusual Injury/Incident Reports (IRs) involving R1 submitted to the department. One IR was submitted to the department on 11/23/2022 and two IRs were submitted to the department on 11/29/2022. The three IRs state that R1’s Responsible Person was notified about each of the incidents.

LPA Marrufo obtained copies of 13 Physician’s Fax Reports sent between facility staff and R1’s Physician. The Physician’s Fax Reports are dated from 09/19/2022 to 12/28/2022. The Physician’s Fax Reports from 11/06/2022, 11/27/2022, and 12/07/2022 indicate that R1’s family was notified.

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SUPERVISORS NAME: Maria Partoza
LICENSING EVALUATOR NAME: David Marrufo
LICENSING EVALUATOR SIGNATURE:	DATE: 07/18/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/18/2025

LIC9099 (FAS) - (06/04)

Page: 3 of 4

Control Number 26-AS-20230103165022

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CENTRAL COAST CR/RES, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131

FACILITY NAME: OAKMONT OF SILVER CREEK	FACILITY NUMBER: 435202772
	VISIT DATE: 07/18/2025

NARRATIVE

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LPA Marrufo obtained copies of email communications between R1’s Responsible Person and the facility Administrator (ADM) at the time the complaint was filed with the department. The email communications are from 12/29/2022 to 01/03/2023. On 12/29/2022, R1’s Responsible Person sent an email to ADM requesting further information about incidents mentioned in the eviction notice given to R1. On 12/30/2022, ADM responded to R1’s Responsible Person’s previous email and stated that ADM would be available for a phone conference on either 01/03/2023 or 01/04/2023 to discuss R1’s Responsible Person’s questions. On 12/30/2022, R1’s Responsible Person responded to ADM’s email and stated to not be available until 01/10/2023. On 01/03/2023, ADM sent an email to R1’s Responsible Person stating that the facility is willing to respond to R1’s Responsible Person’s questions in person and over the phone, but not in writing. ADM asked R1’s Responsible Person to provide a convenient time for them to meet for a discussion.

Based on information from interviews conducted with staff, and records reviewed, although the allegations listed above 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 allegations are unsubstantiated.

No Deficiencies were cited under California Code of Regulations Title 22.

This report was reviewed with Executive Director Minnie Weber and a copy of this report was provided.

Page 4 of 4.

SUPERVISORS NAME: Maria Partoza
LICENSING EVALUATOR NAME: David Marrufo
LICENSING EVALUATOR SIGNATURE:	DATE: 07/18/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/18/2025

LIC9099 (FAS) - (06/04)

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