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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 486803614
Report Date: 07/07/2026
Date Signed: 07/07/2026 02:15:33 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
This is an official report of an unannounced visit/investigation of a complaint received in our office on
04/22/2026 and conducted by Evaluator Julie Florio
COMPLAINT CONTROL NUMBER: 21-AS-20260422105832
FACILITY NAME:OAKWOOD MEMORY & SENIOR CAREFACILITY NUMBER:
486803614
ADMINISTRATOR:REYNALDO GUTIERREZFACILITY TYPE:
740
ADDRESS:1025 OAKWOOD AVENUETELEPHONE:
(707) 643-0473
CITY:VALLEJOSTATE: CAZIP CODE:
94591
CAPACITY:30CENSUS: 13DATE:
07/07/2026
UNANNOUNCEDTIME BEGAN:
11:20 AM
MET WITH:Theresa "TJ" Ilagan, Designated Responsible PartyTIME COMPLETED:
02:30 PM
ALLEGATION(S):
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Staff did not provide proper medication assistance to resident in care.
INVESTIGATION FINDINGS:
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On 07/07/2026, at approximately 11:20 AM, Licensing Program Analyst (LPA) Julie Florio arrived unannounced to conduct a subsequent complaint investigation for the above allegation and deliver findings regarding LIC802 - Complaint Report #21-AS-20260422105832, which was received by Community Care Licensing (CCL) on 04/22/2026. LPA met with Theresa "TJ" Ilagan, Designated Responsible Party (DRP).

On 04/28/2026, durig the initial complaint investigation, LPA btained documents and conducted interviews with facility staff. During the inspection, LPA obtained a physician's report for Resident 1 (R1) dated 04/01/2026 which indicates that R1 is unble to administer their own medications. An interview with Staff 1 (S1) revealed that staff "are trained to stand there and wait until the resident takes the medication." S1 further stated that in this case, "the pill was so tiny, it may have slipped and the staff may have not seen it fall."

Continued on LIC9099C...
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Julie Florio
LICENSING EVALUATOR SIGNATURE:

DATE: 07/07/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/07/2026
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 5
Control Number 21-AS-20260422105832
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: OAKWOOD MEMORY & SENIOR CARE
FACILITY NUMBER: 486803614
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/07/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
08/07/2026
Section Cited
CCR
87465(a)(4)
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87465 Incidental Medical and Dental Care (a) (4) The licensee shall assist residents with self-administered medications as needed.

This requirement is not met as evidenced by:

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Licensee to submit proof of a medication administration re-training of all staff giving medications to CCL by POC due date 08/07/2026.
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Based on documents obtained and interviews conducted, the Licensee did not ensure that R1 took their medication as directed per their physicians orders which posed a potential health, safety, and/or personal rights risk to residents in care.
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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.
SUPERVISOR'S NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Julie Florio
LICENSING EVALUATOR SIGNATURE:

DATE: 07/07/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/07/2026
LIC9099 (FAS) - (06/04)
Page: 5 of 5
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
This is an official report of an unannounced visit/investigation of a complaint received in our office on
04/22/2026 and conducted by Evaluator Julie Florio
COMPLAINT CONTROL NUMBER: 21-AS-20260422105832

FACILITY NAME:OAKWOOD MEMORY & SENIOR CAREFACILITY NUMBER:
486803614
ADMINISTRATOR:REYNALDO GUTIERREZFACILITY TYPE:
740
ADDRESS:1025 OAKWOOD AVENUETELEPHONE:
(707) 643-0473
CITY:VALLEJOSTATE:CAZIP CODE:
94591
CAPACITY:30CENSUS: 13DATE:
07/07/2026
UNANNOUNCEDTIME BEGAN:
11:20 AM
MET WITH:Theresa "TJ" Ilagan, Designated Responsible PartyTIME COMPLETED:
02:30 PM
ALLEGATION(S):
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Staff sleep at the facility while on shift.
INVESTIGATION FINDINGS:
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On 07/07/2026, at approximately 11:20 AM, Licensing Program Analyst (LPA) Julie Florio arrived unannounced to conduct a subsequent complaint investigation for the above allegation and deliver findings regarding LIC802 - Complaint Report #21-AS-20260422105832, which was received by Community Care Licensing (CCL) on 04/22/2026. LPA met with Theresa "TJ" Ilagan, Designated Responsible Party (DRP).

On 04/28/2026, during the iniital complaint investigation, LPA made observations, obtained documents, and conducted interviews with facility staff. During the visit, LPA observed staff alert and engaged with residents in care. Based on a copy of facility's personnel report dated 04/28/2026, the facility schedules at least four caregivers during the late afternoon and evening hours.

Continued on LIC9099C...
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Julie Florio
LICENSING EVALUATOR SIGNATURE:

DATE: 07/07/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/07/2026
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 21-AS-20260422105832
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME: OAKWOOD MEMORY & SENIOR CARE
FACILITY NUMBER: 486803614
VISIT DATE: 07/07/2026
NARRATIVE
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Continued from LIC9099...

Based on documents obtained and interviews conducted, the allegation that staff did not provide proper medication assistance to resident in care is SUBSTANTIATED. A finding that a complaint allegation is SUBSTANTIATED means that the allegation is valid because the preponderance of the evidence standard has been met.

Deficiency is cited from Title 22 Regulations, Division 6, (see LIC9099D).

Exit interview conducted with DRP, whose signature on form confirms receipt of document.
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Julie Florio
LICENSING EVALUATOR SIGNATURE:

DATE: 07/07/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/07/2026
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 21-AS-20260422105832
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME: OAKWOOD MEMORY & SENIOR CARE
FACILITY NUMBER: 486803614
VISIT DATE: 07/07/2026
NARRATIVE
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Continued from LIC9099A...

Further, an interview conducted with Staff 1 (S1) the same day revealed that the evening hours when the incident allegedly occurred are some of the facility's busiest hours "with evening meals, showering, getting ready for bed, medication administration, etc." S1 also stated, "the other staff would have said something to me too." A subsequent interview with S1 today, 07/07/2026, revealed that an internal investigation conducted by the facility with staff concluded that no staff are known to have been sleeping on the job as alleged. Based on interviews conducted, observations made, and records obtained, the Department received conflicting information.

Based on interviews conducted, observations made, and records obtained, the allegation that staff sleep at the facility while on shift is UNSUBSTANTIATED. A finding that a complaint allegation is unsubstantiated means that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is UNSUBSTANTIATED.

No deficiencies cited.

Exit interview conducted with DRP, whose signature on form confirms receipt of document(s).
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Julie Florio
LICENSING EVALUATOR SIGNATURE:

DATE: 07/07/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/07/2026
LIC9099 (FAS) - (06/04)
Page: 3 of 5