Oakmont of Mariner Point

Allegation investigated: Staff did not administer residents' medications as prescribed.

On 9/10/2026 at 11:00 am, Licensing Program Analyst (LPA) Y. Brown arrived unannounced to conduct a complaint investigation and deliver findings for the allegation above. LPA met with Juan Ferrel, Executive Director and explained the purpose of the visit. During investigation, LPA obtained and reviewed the resident roster and staff roster. LPA obtained R1's progress notes, LIC602 (Medical Assessment), June and July Mar (Medication Administration Record), Faxes to physician, and current medications list. Additionally, LPA reviewed staff files and call button (showing alert) sheet. LPA conducted interviews with staff and residents. Continued on LIC9099-C. Substantiated Continued from LIC9099. Allegation: Staff do not respond to residents' calls for assistance in a timely manner. Finding: Unsubstantiated During investigation, LPA visited the facility on 7/7/2026, LPA observed R1 press the call button, but the light did not turn on due to user error. LPA observed R1 press the button a second time and the light turned on. LPA observed a staff member come into R1’s room approximately 5 minutes after to check on R1. On 7/30/2026, LPA observed R4 press their call button and staff responded to the call within approximately 7 minutes. LPA reviewed the call button records and observed that staff have responded to residents’ calls within 10-15 minutes. LPA reviewed the staff schedule and observed there was sufficient staff on duty. Staff interviews stated that they make efforts to respond to residents’ calls for assistance as promptly as possible and provide assistance based on residents’ care needs. Resident interviews stated that occasionally they have to wait for assistance, but overall staff come as soon as they can. Allegation: Licensee does not ensure staff have appropriate training. Finding: Unsubstantiated During record review, LPA reviewed a sample of staff records and identified that staff had up to date and accurate training. Interviews with staff stated that they receive on the job training. Staff stated that they receive in-person and online training. Based on record review, interviews, and observations conducted, the above allegations are unsubstantiated. Although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are unsubstantiated. No deficiency cited. Exit Interview conducted and copy of this report provided. Continued from LIC9099-C. Allegation: Staff did not administer residents' medications as prescribed. Finding: Substantiated During investigation, LPA reviewed R1's MAR (Medication Administration Record) and observed that R1 had a prescription for Bumetanide (Bumex) that had an order to take 2 tablets (1MG) by mouth every morning. LPA reviewed the MAR that indicated that the medication was not administered to R1 on 06/26/2026 due to Consonus Pharmacy not receiving the order. R1 stated that staff usually bring the Bumex medication to them in the morning but they do not remember receiving it that day. S1, S2 and S5 stated that R1 did not receive their morning Bumex medication on 6/26/2026. S5 stated that they contacted the pharmacy to put in a "STAT emergency order" and the medication was delivered in the evening on 6/26/2026. Based on LPA's observation, record review and interviews obtained during investigation, the preponderance of evidence standard has been met; therefore, the above allegation was found to be SUBSTANTIATED. California Code of Regulations, Title 22, are being cited on the attached LIC9099D. Exit interview conducted. A copy of this report and appeal rights provided.the state’s words, verbatim · CDSS document, Sep 10, 2026 · control 15-AS-20260701105724

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87465(a)(4) · Plan of correction due date: Sep 17, 2026

(a) A plan for incidental medical and dental care shall be developed by each facility...: (4) The licensee shall assist residents with self-administered medications as needed. This requirement is not met as evidenced by: Based on record review and interview, the licensee did not comply with the section cited above in that R1 missed their morning medication which poses a potential health risk to persons in care.the state’s words, verbatim · CDSS document, Sep 10, 2026

Plan of correction: By POC date, ED agrees to complete an in-service training regarding regulation 87465 and staff will review all MARs and medications to ensure all residents are taking medications accordingly and submit training to CCLD.

Type of visit: Case Management - Deficiencies

On 9/10/2026 at 2:30 pm, Licensing Program Analyst (LPA) Y. Brown arrived unannounced to conduct a Case Management visit. LPA met with Juan Ferrel, Executive Director and explained the purpose of the visit. While LPA Y. Brown was conducting a complaint investigation (15-AS-20260701105724) on 7/7/2026 during file review and interview LPA discovered: 1. The facility did not submit any incident report regarding R1 missing their prescribed Bumetanide (Bumex) morning medication. The deficiency was observed (see LIC809D) and cited from the California Code of Regulation, Title 22. Failure to correct the deficiencies may result in civil penalties. Exit interview conducted with Juan and a copy of this report and appeal rights provided.the state’s words, verbatim · CDSS document, Sep 10, 2026

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87211(a) · Plan of correction due date: Sep 17, 2026

87211 Reporting Requirements (a) Each licensee shall furnish to the licensing agency such reports as the Department may require, including, but not limited to, the following: This requirement is not met as evidenced by: Based on record review and interview, the licensee did not comply with the section cited above in that the facility did not report that R1 missed their morning medication which poses a potential health risk to persons in care.the state’s words, verbatim · CDSS document, Sep 10, 2026

Plan of correction: By POC due date, the Administrator agrees to complete an all staff in-service retraining on reporting requirements and compliance with section 87211 and send proof of the in-service to CCLD.

Type of visit: Required - 1 Year

On 08/07/2026 at 11:00 AM, Licensing Program Analysts (LPA) David Doidge arrived unannounced to conduct a Case Management visit regarding an incident that was reported to CCLD on 08/04/2026 from an Unusual Incident Report (UIR). LPA met with Executive Director Juan Ferrel and explained the purpose of the visit. LPA reviewed, and obtained copies of, R1’s most recent Physician’s Report and the facility assessment. LPA spoke with Executive Director Juan Ferrel about the incident. R1 is required to wear a safety bracelet, has a Wanderguard, and is unable to leave the facility unassisted. Around 3PM, R1 was taken to room for an afternoon nap. Soon after staff left room, R1 wandered out of room and out of the facility. R1 now has a one-on-one care provider, and the facility is seeking to move R1 into the memory care unit. The deficiency was observed (see LIC809D) and cited from the California Code of Regulation, Title 22. Failure to correct the deficiency may result in civil penalties. Exit interview conducted. A copy of the appeal rights and this report provided.the state’s words, verbatim · CDSS document, Aug 7, 2026

From the deficiency page — Deficiency type: Type B · Section cited: CCR 84768.2(a)(4) · Plan of correction due date: Aug 21, 2026

87468.2 Additional Personal Rights of Residents in Privately Operated Facilities (a) In addition to the rights listed in Section 87468.1, Personal Rights of Residents in All Facilities, residents in privately operated residential care facilities for the elderly shall have all of the following personal rights: (4) To care, supervision, and services that meet their individual needs and are delivered by staff that are sufficient in numbers, qualifications, and competency to meet their needs. This requirement is not met as evidence by: Based on record review and interview, the licensee did not comply with section above by not ensuring care and supervision when R1 eloped which poses an immediate Health & Safety risk to residents in care.the state’s words, verbatim · CDSS document, Aug 7, 2026

Plan of correction: By POC date, the Executive Director agrees to conduct an in-service training with all staff regarding supervision and preventing elopement and send a copy of the training to CCLD.

Type of visit: Case Management - Incident

On 3/4/2026 at 3:35PM, Licensing Program Analyst (LPA) G. Luk arrived unannounced to conduct a case management visit in regards to an incident report. LPA met with Health Services Director, Paolo Valera and explained the purpose of the visit. Based incident report, resident (R1) exited the back door around 5:30PM and alarm was triggered via wander guard. Staff immediately responded by searching for R1 and found R1 in front of a restaurant. During visit, LPA interviewed staff and reviewed R1's file. LPA observed R1's physician's report stated that R1 can leave the facility unassisted. R1's care plan stated resident is to wear safety bracelet when in Assisted Living. LPA advised facility to update R1's physician's report due to R1's change in condition. Health Services Director is in communication with R1's family and will look into obtaining an updated physician's report. No deficiencies are being cited on this date. Exit interview conducted. A copy of this report provided.the state’s words, verbatim · CDSS document, Mar 4, 2026

Type of visit: Case Management - Other

On 3/4/2026 at 3:35PM, Licensing Program Analyst (LPA) G. Luk arrived unannounced to conduct a case management visit in regards to death report received for R1. LPA met with Health Services Director, Paolo Valera and explained the purpose of the visit. Death report revealed that staff check on R1 when family was visiting and R1's family informed staff that R1 passed away. 911 was contacted. During visit, LPA reviewed R1's physician's report, care plan, and care notes. R1 was not on hospice care. R1 has diagnosis which includes hypertensive heart disease and Alzheimer's disease. No deficiencies are being cited on this date. Exit interview conducted. A copy of this report provided.the state’s words, verbatim · CDSS document, Mar 4, 2026

Allegation investigated: Staff do not ensure residents personal property is kept safely secured

On 02/11/2026, at 2:30 PM, Licensing Program Analyst (LPA) James Sampair arrived unannounced to conduct this 10-day complaint visit. The LPA explained the nature of the visit with Executive Director (ED) Juan Ferrel. LPA has determined through an interview with the ED and a review of the resident roster that the complainant does not live at this facility; therefore, the allegation is UNFOUNDED. A finding that is unfounded means the allegation is false, could not have happened, or is without a reasonable basis. An exit interview was conducted and a copy of this report is provided. Unfoundedthe state’s words, verbatim · CDSS document, Feb 11, 2026 · control 15-AS-20260210104513

Allegation investigated: Resident sustained unexplained laceration Staff did not seek timely medical treatment for resident Staff are not providing adequate assistance to resident during feeding times Staff are not properly supervising residents who may be a fall risk Staff are not meeting residents dietary needs

On 9/04/2025 at 1:30 PM Licensing Program Analyst (LPA) Greg Clark arrived unannounced to deliver findings for the above complaint. LPA met with Juan Ferrel, Interim Administrator and explained the purpose of the visit. During the course of the investigation LPA interviewed W1, W2, S1 and S2. There were no other staff available to interview that were employed at the facility during R1’s time there. LPA was unable to interview R1 as she had passed away. R1 was admitted to the facility on 6/10/24 into the Assisted Living part of the facility. On 9/24/24 R1 was moved to the Memory Care side of the facility due to complications due to a fall. (LPA did receive LIC624 for this incident) From that time forward there were 3 more moves between Memory Care and Assisted Living. ***report continues on LIC9099C*** Unsubstantiated ***report continues from LIC9099*** On 11/21/24 R1 was placed on Hospice and on 2/19/25 R1 moved to Memory Care for the last time. R1 was discharged from the facility on 3/17/25 to a 6 bed RCFE operated by W1. S1, S2 and W2 all stated that R1’s health was in decline during her time at the facility. Allegation: Resident sustained unexplained laceration W1 was concerned about the open sores on R1’s heels and considered them to be a laceration. W2 stated that staff were monitoring the condition of R1’s heels on a daily basis. Staff would try to get R1 to lie in bed with her feet elevated so the heels were not in contact with the bed sheets, but she often refused. W2 also stated that she would not consider the sores on R1’s feet to be unexplained laceration. Allegation: Staff did not seek timely medical treatment for resident W1 had no specific information regarding this allegation stating that she “had a feeling” that the residents at the facility were being neglected and that it should be investigated. During the time period outlined in the complaint R1 was on Hospice and receiving regular visits from the Hospice nurse (W2). W2 stated that she was in contact with R1’s physician as needed and felt that R1 received all the medical care she needed in a timely manner. Allegation: Staff are not providing adequate assistance to resident during feeding times W1 never observed R1 during mealtimes but did observe food on her mouth and clothing. S1 and S2 state that R1 would often refuse to eat or eat very little. LPA reviewed R1’s care notes from January 2025 to March 15, 2025, and saw several entries stating that “R1 didn’t eat much,” and “R1 refused breakfast.” Allegation: Staff are not properly supervising residents who may be a fall risk W1 stated that on one of her visits to the facility she found R1 lying in bed with both legs hanging on the left side of the bed with no supervision and the bedroom door shut. S2 stated that residents in the Memory Care Unit who are identified as a fall risk are put on an increased level of supervision, these residents are checked hourly or more as needed. R1 was considered a fall risk and care notes reviewed by LPA document that staff were checking on R1 on a regular and routine basis and would occasionally find R1 trying to get out of her bed or wheelchair in the same manner as described above. ***report continues on LIC9099C*** ***report continues from LIC9099C*** Allegation: Staff are not meeting residents’ dietary needs W1 stated that between her visits to the facility it appeared that R1 had lost weight, and she felt that the staff weren’t monitoring R1 close enough during mealtimes to ensure that she eats her food. W1 asked facility staff, names unknown, about R1’s diet and staff replied that R1 doesn’t eat much and that they try their best, but they can’t force her to eat. S2 stated that R1 had a very poor appetite and that she often would refuse to eat. S2 also stated that staff would offer R1 dietary supplement drinks which R1 would drink occasionally. This agency has investigated the above complaints. We have found that the complaints are unsubstantiated. Although the 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 allegations are UNSUBSTANTIATED. Exit interview conducted, a copy of this report provided.the state’s words, verbatim · CDSS document, Sep 4, 2025 · control 15-AS-20250327161639

Type of visit: Required - 1 Year

On 9/04/25, Licensing Program Analyst (LPA) Greg Clark arrived unannounced to conduct 1-Year Annual Required inspection. LPA met with Juan Ferrel, Interim Administrator and explained the purpose of the visit. LPA toured the facility including but not limited to 4 residents’ apartments, bathrooms, multiple activity rooms, kitchen, common area and courtyard. There are no bodies of water observed. LPA observed lighting in all rooms are adequate for the comfort and safety of the residents. Hallway temperature was maintained at 70 degrees F. The hot water temperature at a sink in the hallway bathroom was measured at 135.1 degrees Fahrenheit. Residents’ bathrooms are equipped with grab bars and non-skid mats. There is a minimum of one week supply of nonperishable and 2-day of perishable foods. Centrally stored medications, sharps and toxic are locked and inaccessible to residents in care. Smoke detectors and carbon monoxide detectors were in operating condition during visit. Fire extinguisher was last serviced on 1/09/25. Emergency Disaster Plan was last posted on 9/04/25. First aid kit was observed to be complete. Emergency disaster drill was last conducted on 6/15/25. LPA reviewed 5 residents records and 5 staff records, and all were complete. LPA also reviewed a sample of resident’s medications. THE FOLLOWING DEFICIENCY WAS OBSERVED: hot water temperature at a sink in the hallway bathroom was measured at 135.1 degrees Fahrenheit. The above deficiency was observed (see LIC 809D) and cited from the California Code of Regulations. Failure to correct deficiency by POC date may result in additional Civil Penalties. Exit interview conducted with Administrator. LIC809D, Appeal Rights and a copy of this report provided.the state’s words, verbatim · CDSS document, Sep 4, 2025

Allegation investigated: Staff dispense medication to residents without appropriate training. Staff mismanage residents’ medications. Staff do not provide adequate supervision for residents.

On 9/17/24 at 2:15 p.m., Licensing Program Analyst (LPA) Greg Clark arrived unannounced to deliver findings in regard to the allegations above. LPA met with Jannelle Douglas, Administrator and explained the purpose of the visit. During the course of the investigation LPA reviewed facility records and interviewed staff. Allegation: Staff dispense medication to residents without appropriate training. At the time of the complaint the facility had 5 med techs and 1 med tech in training. The LPA reviewed the training records for 5 med techs (S2, S3, S4, S5 and S6) all had proper medication training. S1 also dispenses medication as needed and review of S1’s file documented that S1 has the required training to pass medication. This allegation in unsubstantiated. ***report continues on LIC9099C*** Unsubstantiated ***report continues from LIC9099*** Staff mismanage residents’ medications. LPA reviewed medication administration records (MARs) for R1, R2 and R3 and found no evidence that any of their medications were mismanaged. All 3 residents received their medications as prescribed and properly documented on the MAR. This allegation in unsubstantiated. Staff do not provide adequate supervision for residents. LPA interviewed S1 and S7 who are responsible to manage transportation for residents who need assistance in getting to their doctors’ appointment. Both stated that residents are either transported by family or in the facility van with staff accompanying them if needed. Both stated that no residents with dementia are ever put in an Uber to be transported by themselves to a doctors’ appointment. This allegation in unsubstantiated. This agency has investigated the above allegations. We have found that the allegations were unsubstantiated. Although the 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 allegations are UNSUBSTANTIATED. Exit interview conducted, a copy of this report provided.the state’s words, verbatim · CDSS document, Sep 17, 2024 · control 15-AS-20240613164149

Type of visit: Required - 1 Year

On 9/17/24 at 10:30 AM, Licensing Program Analyst (LPA) Greg Clark arrived unannounced to conduct 1-Year Annual Required inspection. LPA met with Jannelle Douglas, Administrator and explained the purpose of the visit. LPA toured the facility including but not limited to 4 residents’ apartments, bathrooms, multiple activity rooms, kitchen, common area and courtyard. There are no bodies of water observed. LPA observed lighting in all rooms are adequate for the comfort and safety of the residents. Hallway temperature was maintained at 70 degrees F. The hot water temperature at a sink in the kitchen was measured at 117.2 degrees Fahrenheit. Residents’ bathrooms are equipped with grab bars and non-skid mats. There is a minimum of one week supply of nonperishable and 2-day of perishable foods. Centrally stored medications, sharps and toxic are locked and inaccessible to residents in care. Smoke detectors and carbon monoxide detectors were in operating condition during visit. Fire extinguisher was last serviced on 1/03/24. Emergency Disaster Plan was last posted on 7/15/24. First aid kit was observed to be complete. Emergency disaster drill was last conducted on 6/15/24. LPA reviewed 5 residents records and 5 staff records, and all were complete. LPA also reviewed a sample of resident’s medications. No deficiencies cited during visit. Exit interview conducted and a copy of this report provided.the state’s words, verbatim · CDSS document, Sep 17, 2024

Allegation investigated: Staff left resident without care and supervision for an extended period of time. Resident in care developed a wound due to lack of staff supervision. Staff did not ensure that resident's hygiene needs were met while in care Staff did not ensure that resident was fed while in care. Staff did not follow personal hygiene and sanitation practices.

On 8/09/24 at 11:00 a.m., Licensing Program Analyst (LPA) Greg Clark arrived unannounced to conduct an initial 10-day complaint investigation and deliver findings in regard to the allegations above. LPA met with Jannelle Douglas, Administrator and explained the purpose of the visit. During the course of the investigation LPA attempted to reach the Reporting Party (RP) by phone and email. RP never contacted LPA. LPA interviewed W1, R1’s son. W1 stated that the care R1 received at the facility was “exceptional.” W1 visited R1 on a daily basis and never observed any of the allegations cited in the complaint. W1 stated that the care R1 received at the facility was “the complete opposite” of what is stated in the complaint. W1 further stated that the “care and love” R1 received at the facility was “transformational” for R1. ***report continues on LIC9099C*** Unsubstantiated ***report continues from LIC9099*** At the facility LPA reviewed R1’s file and interviewed S1 and S2 and toured the memory care unit. R1 was admitted to the facility on 3/23/2024, admitted to hospice on 4/08/24 and passed away on 7/23/24. S1 stated that she never heard any complaints about R1’s care from R1’s Responsible Party. S1 did state that she heard that the RP was rude to the facility staff and was very disruptive during her visits to the Memory Care Unit where R1 resided. S2 stated that R1 was monitored closely by the Memory Care Unit staff and was never left unsupervised for extended periods of time. R1 did develop several wounds while in care due to R1 being bed bound while also being very restless. The wounds were treated as prescribed and never developed past Stage 1. S2 further stated that R1’s was given bed bath’s 3 times weekly. LPA confirmed this by reading the care notes in R1's chart. Allegation: Staff left resident without care and supervision for an extended period of time. R1 was visited by W1 on a daily basis. W1 always observed that staff were attending to R1. R1 also had visits from Hospice 3 - 4 times a week and a Nurse twice weekly. Review of chart notes do not document any concerns about R1’s care and supervision. This allegation is unsubstantiated. Allegation: Resident in care developed a wound due to lack of staff supervision. R1 did develop wounds while in care. S2 stated that it is not uncommon for bed bound residents on hospice to develop these types of wounds. S2 further stated that R1’s wounds were not due to a lack of staff supervision but due to R1’s deteriorating condition. This allegation is unsubstantiated. Allegation: Staff did not ensure that resident's hygiene needs were met while in care. Review of R1’s chart and interview with S2 revealed that R1 was receiving assistance with his activities of daily living on a daily basis and receiving bed baths 3 times weekly. This allegation is unsubstantiated. ***report continues on LIC9099C*** ***report continues from LIC9099C*** Allegation: Staff did not ensure that resident was fed while in care. Over the course of R1’s time at the facility (4 months) R1 went from being on a regular diet and able to feed himself independently to being placed on a puree diet where he needed staff assistance. S2 stated that R1 simply lost to desire to eat and that R1 always had a staff person assigned to him to assist during meals. This allegation is unsubstantiated. Allegation: Staff did not follow personal hygiene and sanitation practices. LPA toured Memory Care Unit and observed all staff wearing gloves and masks. Hand washing signs are posted by each sink. S2 stated that all staff receive training on personal hygiene and sanitation practices. LPA asked 2 memory care staff when they are required to wash their hands, both replied "all the time." This allegation is unsubstantiated. This agency has investigated the complaint alleging staff left resident without care and supervision for an extended period of time, resident in care developed a wound due to lack of staff supervision, staff did not ensure that resident's hygiene needs were met while in care, staff did not ensure that resident was fed while in care and staff did not follow personal hygiene and sanitation practices. We have found that the complaint was unsubstantiated. Although the 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. Exit interview conducted, a copy of this report provided.the state’s words, verbatim · CDSS document, Aug 9, 2024 · control 15-AS-20240801103608

Allegation investigated: Facility air conditioning is in disrepair Facility staff not meeting Residents incontinent care. Facility not meeting Residents needs due to insufficient staffing

On 11/21/23 at 12:45 p.m., Licensing Program Analyst (LPA) Greg Clark arrived unannounced to deliver findings on the above allegations. LPA met with Caroline Frangieh, Interim Administrator and explained the purpose of the visit. Facility air conditioning is in disrepair The air conditioning in the common area of the memory care unit was reported by staff to be in disrepair on 7/18/23. LPA reviewed a repair invoice from J.R. Heating and Cooling dated 7/19/23 stating that the needed repairs to the A/C unit were completed by close of business on 7/19/23. ***report conintues on LIC9099C*** Unsubstantiated ***report continues from LIC9099*** Facility staff not meeting Residents incontinent care, Facility not meeting Residents needs due to insufficient staffing LPA reviewed facility’s Urinary Incontinence policy. The policy states that residents with urinary incontinence will receive appropriate care by facility staff. LPA reviewed the staff schedule for Sunday 7/16/2023. On 7/16/23 there was 1 med tech and 1 care staff assigned to work in memory care and 2 other care staff were transferred from assisted living to memory care to provide additional support. The Memory Care Director was also on site. The memory care census on this weekend was 22. Facility does not document incontinence care however there were sufficient staff in the memory care unit on 7/16/23 to provide appropriate care. This agency has investigated the complaints alleging facility air conditioning is in disrepair, facility staff not meeting residents incontinent care and facility not meeting residents needs due to insufficient staffing. We have found that the complaints were unsubstantiated. Although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are UNSUBSTANTIATED. Exit interview conducted, a copy of this report provided.the state’s words, verbatim · CDSS document, Nov 21, 2023 · control 15-AS-20230718134653