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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 079201085
Report Date: 03/19/2025
Date Signed: 03/19/2025 10:44:10 AM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
This is an official report of an unannounced visit/investigation of a complaint received in our office on
01/15/2025 and conducted by Evaluator Lisha Holmes
PUBLIC
COMPLAINT CONTROL NUMBER: 15-AS-20250115085215
FACILITY NAME:OAKMONT OF CONCORDFACILITY NUMBER:
079201085
ADMINISTRATOR:SOR, KIM SFACILITY TYPE:
740
ADDRESS:1401 CIVIC COURTTELEPHONE:
(925) 798-4004
CITY:CONCORDSTATE: CAZIP CODE:
94520
CAPACITY:121CENSUS: 93DATE:
03/19/2025
UNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Kim Sor, Executive DirectorTIME COMPLETED:
10:00 AM
ALLEGATION(S):
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Staff engaged in inappropriate behavior resulting in resident sustaining in injury.
INVESTIGATION FINDINGS:
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On 03/19/25 around 9:00 AM, Licensing Program Analyst (LPA) L. Holmes arrived unannounced to deliver the finding for the above allegation. LPA met with Kim Sor, Executive Director (ED) and explained the purpose of the visit.

During the investigation and visits, LPA L. Holmes and L. Alexander toured the facility, interviewed Staff (S1, S2, S4, S5), reviewed statements from S2, S3 and S6, and reviewed the following documents: Resident Roster and Personnel Record (LIC500) designating Memory Care (MC), R1's LIC602, R1’s ID/Emergency contact information, and R1’s LIC624. Executive Director (ED) provided the local police report number and internal investigation report.

Continued on LIC9099...
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Lisha Holmes
LICENSING EVALUATOR SIGNATURE:

DATE: 03/19/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/19/2025
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 2
Control Number 15-AS-20250115085215
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME: OAKMONT OF CONCORD
FACILITY NUMBER: 079201085
VISIT DATE: 03/19/2025
NARRATIVE
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...continued from LIC9099.

Allegation: Staff engaged in inappropriate behavior resulting in resident sustaining in injury.

On 01/14/25 R1, a resident of Memory Care, attempted to enter the dining room by trailing S3 which was where other staff members were preparing for the evening meals. Records and interviews from S1, S3, S4, S5 and S6 revealed that R1’s fall was not a result of S3’s inappropriate behavior. S1 stated that R1 was yelling, swearing, tugging at the dining room door, and lost his/her balance. S4 assisted with calming R1 as he/she did not want to be restrained by the paramedics for medical attention, and S5 stated, “Perhaps S3 was not aware of R1 behaviors. R1 was getting agitated, combative, and slapping our (S4, S5 and EMT’s) hands. As of late, R1 has been a fall risk and is on Hospice medication. R1 is always walking, touching things, and standing.” Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did occur, therefore, the allegation is UNSUBSTANTIATED.

Exit interview conducted and a copy of this report provided to ED.
SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Lisha Holmes
LICENSING EVALUATOR SIGNATURE:

DATE: 03/19/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/19/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 2