Oakmont of Santa Clarita

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Allegation investigated: Resident sustained multiple injuries due to staff neglect or abuse.

This report was amended for gramatical and technical erros only. The findings and facts have not changed. This report supercedes the report dated March 27, 2026. Licensing Program Analyst, Abeye Duguma (LPA) conducted an initial complaint visit to investigate the allegation. LPA met with Cruz Espinoza and explained the reason for the visit. ---Resident sustained multiple injuries due to staff neglect or abuse. It was alleged that Resident #1 (R1) has had an estimated ten (10) head injuries in the past year. To investigate the allegation, on March 27, 2026 at around 10:00a.m. LPA requested documents. At around 11:30a.m., LPA interviewed one (01) staff. LPA was unable to interview R1 as they are no longer a resident. R1’s Admissions Agreement from Oakmont of Santa Clarita is dated February 29, 2024 and the Admissions Agreement at Oakmont of Valencia is dated March 19, 2024. R1 is currently at Oakmont of Valencia in Memory Care. (CONT. on LIC9099-C) Unsubstantiated A review of R1's ledger indicates they lived in this facility from February 29, 2024 to March 19, 2024. A review of the Department’s records do not indicate R1 had a fall in the past twelve (12) months or time in question. During interviews, staff stated R1 hasn’t lived here in a long time. R1 lives over at the other Oakmont, Oakmont of Valencia. R1 was only here for about two (02) months. Staff added they are unaware of multiple falls during R1’s stay. Based on interviews and record review, there is not enough information to verify the allegation. Therefore, the allegation is unsubstantiated at this time. No health and safety hazards noted during the visit. Exit interview conducted and a copy of the report was issued.the state’s words, verbatim · CDSS document, Mar 27, 2026 · control 31-AS-20260324130624

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Abeye Duguma conducted an unannounced Case Management visit regarding a recent incident report submitted 02/09/2026. The Serious Incident Report (SIR) states Resident #1 (R1) was given the wrong medications by Staff #1 (S1). The medications were prepared for multiple residents and S1 handed R1 the wrong cup. Upon noticing, the facility immediately contacted R1’s physician and responsible party by phone and notified the Department via fax. The facility was instructed by the physician to monitor the resident for any changes as the resident was not in any immediate danger. R1 did not experience any change in condition. Subsequently, S1 completed additional training and has not had a repeated incident to date. A review of facility files shows that S1 was fingerprint cleared and completed all training. LPA randomly selected three (03) MedTech files all of which had completed their training. A copy of the completed training logs and training material was provided. (CONT. on LIC809-C) On 12/15/2025, LPA conducted a Case Management visit for a similar medication mismanagement incident. Pursuant to Title 22 Division 6 Chapter 8 of the CA Code of Regulations, the following deficiencies were cited (refer to LIC 809-D): No other heath and safety hazards noted during the visit. Nothing further at this time. Exit interview conducted and a copy of the report was issued.the state’s words, verbatim · CDSS document, Feb 12, 2026

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(a)(2) · Plan of correction due date: Feb 16, 2026

87465 Incidental Medical and Dental Care (a)(2)The licensee shall provide assistance in meeting necessary medical and dental needs. This requirement is not met as evidenced by; Based on interviews and record review, R1 was given incorrect medication by S1.the state’s words, verbatim · CDSS document, Feb 12, 2026

Plan of correction: Administrator will provide proof of additional medication training.

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Abeye Duguma conducted an unannounced Case Management visit regarding a recent incident report submitted 12/15/2025. The Serious Incident Report (SIR) states Resident #1 (R1) was given the wrong medications by Staff #1 (S1). The facility immediately contacted R1’s physician and responsible party by phone and notified the Department via fax. The facility was instructed by the physician to monitor the resident for any changes as the resident was not in any immediate danger. R1 did not experience any change in condition. Subsequently, S1 completed additional training but has since left the organization. A review of facility files shows that S1 was fingerprint cleared and completed all training. LPA randomly selected three (03) MedTech files all of which had completed their training. A copy of the completed training logs and training material was provided. No other heath and safety hazards noted during the visit. Nothing further at this time. Exit interview conducted and a copy of the report was issued.the state’s words, verbatim · CDSS document, Dec 17, 2025

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Abeye Duguma met with the Executive Director, Tom Park, for a Required One (01) Year visit. LPA explained the reason for the visit. A tour of the physical plant was conducted at around 9:00a.m. and the following was noted: The facility has outdoor furniture with a covered shaded area for residents and visitors. The facility does not have a swimming pool. The facility is fire cleared for one hundred twenty-one (121) non-ambulatory, of which eight (08) may be bedridden, and a hospice waiver for fifteen (15). The facility is currently occupying ninety-seven (97) residents. The common and dining areas are clean and appropriately furnished. The facility consists of eighty-six (86) resident rooms. A random selection of bedrooms were toured in both Memory Care and Assisted Living. All bedrooms were properly furnished and had appropriate bed linens. The residents' rooms are adequately furnished with appropriate lighting system. Hallways are well lit. The bathrooms were toured and observed to be clean. Nonskid mats and grab bars were observed in all bathrooms. Residents have enough personal hygiene product provided by the licensee. Towels and washcloths are not shared. There was enough clean linen available in the cabinets. (continued on LIC 809-C) Kitchen is sufficiently stocked with at least two (02) days perishable and seven (07) days non-perishable food. Frozen foods are wrapped and stored appropriately. Food storage and preparation areas are clean and inaccessible to pests. Knives and sharps are observed to be locked and inaccessible to residents. The facility maintains a comfortable temperature at 77°F. The smoke and carbon monoxide detectors are hardwired, interconnected and inspected periodically. The fire alarms are programmed to dispatch the local fire department. Fire extinguishers are located throughout the facility, observed to be fully charged and last inspected on 01/14/2025. The average hot water temperature was measured at 115.2°F. Facility maintains a complete first aid kit. LPA observed medication to be locked and inaccessible to residents. Laundry detergents, cleaning agents and other toxins are locked away. No health and safety hazards noted during the visit. Exit interview conducted. Copy of this report issued.the state’s words, verbatim · CDSS document, Sep 12, 2025

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Abeye Duguma met with the Executive Director, Tom Park, for a Required One (01) Year visit. LPA explained the reason for the visit. A tour of the physical plant was conducted at around 9:00 AM and the following was noted: There is one entrance being utilized at the facility. The facility consists of eighty-six (86) rooms. The rooms consists of single or shared occupancy. A random selection of bedrooms was toured both in Memory Care and Assisted Living. All bedrooms were properly furnished and had appropriate bed linens. The rooms were observed to be sanitary. The bathrooms were toured and observed to be clean and properly stocked with towels and soap. Nonskid mats and grab bars were observed in all bathrooms. The facility is fire cleared for one hundred twenty-one (121) non-ambulatory, of which eight (08) may be bedridden, and a hospice waiver for fifteen (15). The facility is currently occupying ninety-nine (99) residents. The facility has outdoor furniture with a covered shaded area for residents and visitors. The facility does not have a swimming pool. Laundry detergents, cleaning agents and other toxins are locked away. Kitchen is sufficiently stocked with at least two (02) days perishable and seven (07) days non-perishable food. Frozen foods are wrapped and stored appropriately. Food storage and preparation areas are clean and inaccessible to pests. Knives and sharps are observed to be locked and inaccessible to residents. (continued on LIC 809-C) The living and dining room are neat and clean. The facility maintains a comfortable temperature at 76°F. The smoke and carbon monoxide detectors are hardwired, interconnected and inspected periodically. The fire alarms are programmed to dispatch the local fire department. Fire extinguishers are located throughout the facility, observed to be fully charged and last inspected on 01/12/2024. The residents' rooms are adequately furnished with appropriate lighting system. Hallways are well lit. Residents have enough personal hygiene product provided by the licensee. The bathroom was checked for cleanliness and proper operations. The average hot water temperature was measured at 117.4°F. Towels and washcloths are not shared. There was enough clean linen available in the cabinets. LPA observed medication to be locked and inaccessible to residents. Facility maintains a complete first aid kit. No health and safety hazards noted during the visit. Exit interview conducted. Copy of this report issued.the state’s words, verbatim · CDSS document, Sep 6, 2024

Allegation investigated: Staff did not ensure the facility hot water was not in disrepair

Licensing Program Analyst (LPA) Abeye Duguma conducted an unannounced subsequent complaint visit to this facility to investigate the above allegation. LPA met with Tom Park and explained the reason for the visit. ---Staff did not ensure the facility hot water was not in disrepair It was alleged that the facility has intermittent hot water since 02/27/2024 and that residents are complaining about not being able to take hot showers. To investigate the allegation, on 03/21/2024 LPA conducted physical plant tour at around 11:00 AM, requested pertinent documents at 12:00 PM and interviewed staff between 12:30 PM to 02:30 PM. During the physical plant tour, LPA observed a hot water temperature of 111.4°F. A review of the facility’s Work Order records shows that 02/27/2024 a work order was initiated for no hot water in rooms #245, #244 and #239. (CONT. on LIC 9099-C) Substantiated During interviews with staff, Staff #3 stated there were issues with some of the wiring and parts but that a third-party company was immediately contact to resolve the issue. All other staff stated they did not experience any hot water issues and were only made aware of the issue when they witnessed other agencies in the facility to address the problem. Based on interviews and record review, there is enough information to verify the allegation. Therefore, the allegation is SUBSTANTIATED at this time. Pursuant to Title 22 Division 6 Chapter 8 of the CA Code of Regulations, the following deficiencies were cited (refer to LIC 9099-D): No other health and safety hazards noted during the visit. Exit interview conducted. Copy of this report issued.the state’s words, verbatim · CDSS document, Jul 25, 2024 · control 31-AS-20240319143437

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87303(a) · Plan of correction due date: Jul 25, 2024

87303 Maintenance and Operation (a) The facility shall be clean, safe, sanitary and in good repair at all times. This requirement is not met as evidenced by; Based on interviews and record review, hot water was not available in the facility for a given time which poses a potential health, safety and personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Jul 25, 2024

Plan of correction: A plan of correction was not issued as the facility took the necessary measures to have the hot water repaired and LPA observed hot water temperature at 111.4°F.