Oakmont Of Torrance

Report on file with the state — no findings text was published for this visit. The complete document is on the state’s site.

Allegation investigated: Staff did not seek medical attention for resident Staff did not reassess resident's blood pressure in a timely manner

On 12/16/2025, Licensing Program Analyst (LPA) Wendy Gibbs conducted an unannounced Complaint Visit to the facility. LPA met with Health Services Director, Angelie ‘Angel’ Pasa, and the purpose of today’s visit was explained. LPA was granted entry into the facility. The investigation consisted of the following: During today’s visit, LPA interviewed Staff S1-Staff S8. During a subsequent visit conducted on 11/13/2025, LPA interviewed Residents R1-R8 and received and reviewed resident R1’s Admission Agreement (dated 10/01/2020), On-Site Activity (dated 09/29/2020 through 10/14/2025), Resident Charges/Payment Ledger (dated 10/02/2020 through 11/13/2025), and Charting Notes for R1. During the initial visit conducted on 10/16/2025, LPA inspected the facility and received and reviewed Staff Roster, Resident Roster, Resident Physician’s Report (dated 03/19/2025 and 04/08/25, Physician Orders, Individual Service Plan (dated 08/04/2025 and 07/16/2025), Shift Report (dated 10/06/25 through 10/16the state’s words, verbatim · CDSS document, Dec 16, 2025 · control 11-AS-20251014150501

Report on file with the state — no findings text was published for this visit. The complete document is on the state’s site.

Allegation investigated: Facility staff did not follow residents’ dietary restrictions. Facility staff did not adequately prepare resident food.

On 11/13/2025, Licensing Program Analyst (LPA), Wendy Gibbs, conducted an unannounced subsequent Complaint Visit to the facility listed above. LPA met with Executive Director, Judith Uy-Villaruz, and the purpose of the visit was explained. LPA was granted entry into the facility. The investigation consisted of the following: During today’s visit, LPA interviewed Residents R1-R8 and received and reviewed kitchen staff Relias Training, Nutricopia Consultant Dietitian Report Card for Assisted Living, and Food Handlers Certification. During the initial visit conducted on 10/16/2025, LPA inspected the kitchen and facility, interviewed Staff S1-S6, and received documents pertinent to the investigation. The following documents were received and reviewed Staff Roster, Resident Roster, Resident Physician’s Report, Physician Orders, Dietary Orders, Individual Care Plan (dated 08/04/2025 and 07/16/2025), Resident Dietary Information, Diet Clarification Request (dated 08/08/2025), Menu for Octoberthe state’s words, verbatim · CDSS document, Nov 13, 2025 · control 11-AS-20251010155228

Allegation investigated: Staff sexually abused resident in care.

On 10/16/2025, at 9:30 am, the department made an unannounced subsequent visit to the facility and was greeted by Executive Director, Judy Uy. The purpose of today’s visit was to deliver findings in the complaint investigation. The investigation consisted of the following: On 03/25/25 at 08:25am, the department conducted an initial visit and met with Judy Uy, Executive Director. During the initial visit, the department conducted a health and safety tour of the facility’s Memory Care Unit and observed residents in care. The department obtained copies of the following documents: Staff Roster (Dated: 02/25/2025), Staff Schedule for (03/16/2025 to 03/29/2025), Resident Roster (Dated: 03/24/2025), Personal Data Form for staff (S1), Termination Letter for S1 (Dated: 03/24/2025), Employment Application (Dated: 11/25/2024), Disciplinary Action Notice (Dated: 02/10/2025), Relias Training Transcript (Various Dates), Resident Information Form, Physician’s Report for resident (R1) (Dated: 03/20/20the state’s words, verbatim · CDSS document, Oct 16, 2025 · control 11-AS-20250324160525

Allegation investigated: Due to lack of supervision, resident physically assaulted another resident

On 09/17/2025, Licensing Program Analyst (LPA), Wendy Gibbs, conducted an unannounced subsequent Complaint Visit to the facility listed above. LPA met with Executive Director, Judith Uy, and the purpose of today’s visit was explained. LPA was granted entry into the facility. The investigation consisted of the following: During today’s visit LPA interviewed Staff S4-S7, interviewed Residents R2, R8-R10, and received staff In-Service Training logs. During an initial visit conducted on 09162025, LPA interviewed Staff S1-S3 and S8, interviewed Residents R1-R7, interviewed Psychiatric Nurse Practitioner from Access Healthcare Associates and received documents pertinent to the investigation. The following documents were received and reviewed Staff Roster, Resident Roster, Staff Schedule, Physician’s Report, Physician’s Orders, Preplacement Appraisal Information (dated , Behavioral Expression Appraisal (dated 02/12/2025 and 09/07/2026), Resident Assessment (dated 08/03/2025), Individualized Sthe state’s words, verbatim · CDSS document, Sep 17, 2025 · control 11-AS-20250909113956

Report on file with the state — no findings text was published for this visit. The complete document is on the state’s site.

Report on file with the state — no findings text was published for this visit. The complete document is on the state’s site.

Report on file with the state — no findings text was published for this visit. The complete document is on the state’s site.

Allegation investigated: Staff did not adequately assist resident with repositioning.

On 01/29/25, the department conducted a subsequent unannounced compliant visit to deliver the findings. The department met with Administrator, Judith Uy and Health Services Director, Angel Pasa, and the purpose of today’s visit was explained. On 10/31/24, the department conducted a subsequent unannounced complaint visit to the facility. During the visit, the department conducted a facility tour, interviewed Residents R1 and R7-R10, and received documents pertinent to the investigation. The following documents were received and reviewed current Home Health Agency Care Notes, and an updated resident reminders to assist with turning each shift. During the initial visit conducted on 10/02/24 the department toured the facility, interviewed Staff (S1- S10), interviewed Residents (R2-R6), and received documents pertinent to the investigation. The following documents were received and reviewed: Staff roster, Resident Roster, Resident Information Form, resident Physician’s Report, Assessment Suthe state’s words, verbatim · CDSS document, Jan 29, 2025 · control 11-AS-20240925165205

Allegation investigated: Staff did not folow advanced directives and requests regarding resuscitative measures

On 01/15/2025, the department conducted an unannounced complaint visit to the facility listed above. The department met with Health Service Director, Angelie Pasa, and the purpose of today’s visit was explained. During today’s visit the department conducted a facility tour, interviewed Staff S1-S6, and received documents pertinent to the investigation. The following documents were received and reviewed: Staff Roster, Resident Roster, Resident Face Sheet, Resident Information Form, Physician Orders for Life-Sustaining Treatment (POLST), Physician’s Report (LIC602A), Physician’s Orders, and Follow Up Encounter Notes from Senior Doc CA. The investigation revealed the following: Continued On LIC9099-C Unsubstantiatedthe state’s words, verbatim · CDSS document, Jan 15, 2025 · control 11-AS-20250107091829

Report on file with the state — no findings text was published for this visit. The complete document is on the state’s site.

Allegation investigated: Staff did not provide adequate food service Untrained staff

On 04/24/24, Licensing Program Analyst (LPA), Wendy Gibbs, conducted an unannounced complaint visit to the facility listed above. LPA met with Executive Director, Judith Uy-Villaruz, and the purpose of today’s visit was explained. During today’s visit, LPA toured the facility, interviewed Staff (S1-S8), interviewed Residents (R1-R13), and received documents pertinent to the investigation. The documents include the Staff Roster, Resident Roster, Dining Menu, In-Service Training Log, Dining Schedule, Server Job Description, Server Binder, Team Member Handbook and Dining Procedure. The investigation revealed the following: Continued on LIC9099 Unsubstantiatedthe state’s words, verbatim · CDSS document, Apr 24, 2024 · control 11-AS-20240416143550

Report on file with the state — no findings text was published for this visit. The complete document is on the state’s site.

Allegation investigated: Resident sustained a fall while in care. Staff did not seek timely medical attention for a resident. Resident developed multiple pressure injuries while in care.

On 03/14/24, Licensing Program Analysts (LPAs) Ernand Dabuet and Troy Watson conducted a subsequent unannounced complaint investigation visit for the allegations listed above. Today’s complaint investigation was conducted with administrator Judith Uy-Villaruz. The purpose of the visit is to deliver the findings for this complaint. The investigation consisted of the following: LPA obtained copies of the roster for Resident and Staff. Interviews with administrator (A#1), staff #1-3 (S1-S3), residents #1-#9 (R1-R9), and witness #1 (W1). A reviewed of (R1's) Service records, Hospice records, and Medical records, and other pertinent documents associated with this complaint. A tour of the facilty conducted on 12/09/22, 03/01/24, 03/14/24. (Evaluation Report continues LIC 9099-C) Unsubstantiatedthe state’s words, verbatim · CDSS document, Mar 14, 2024 · control 11-AS-20221128132320

Allegation investigated: Facility staff do not assist resident with grooming as needed. Facility staff donot ensure resident wears clean clothing. Facility staff do not ensure resident has clean bed linens. Facility staff do not assist resident with bathing as needed.

On 02/14/2024, Licensing Program Analyst (LPA) Antonine Richard conducted a complaint visit to deliver findings. LPA met with Resident Care Coordinator Charisma lepue and Health Services Director Angelie Pasa and the purpose of today’s visit was explained. Later LPA Richard met with Executive Director Matthew Ryan and obtained documents. The investigation consisted of the following: LPA observed facility, as well as common areas of the facility. A comfortable temperature is maintained throughout the facility. LPA observed the facility to be operational and in good repair, LPA reviewed pertinent documents pertaining to the investigation. The following documents were gathered: Staff and Client Rosters, file for resident (R1) and any other pertinent documentation needs and service, residency agreement, Individualized Service Plan, housekeeping cleaning schedule, resident shower schedule and care giver schedule. Unsubstantiatedthe state’s words, verbatim · CDSS document, Feb 14, 2024 · control 11-AS-20240206153313

Allegation investigated: Resident wandered away from facility due to lack of supervision resulting in hypothermia. Staff did not notify police of missing resident.

Licensing Program Analyst (LPA) Ernand Dabuet made an unannounced visit to the facility and was greeted by Activity Director (S10: Cortney Holmes). LPA conducted a risk assessment prior to entering the facility and observed COVID-19 protocol. (S10) informed LPA that the facility has no COVID cases nor do any of the residents or staff have symptoms. The purpose for today’s visit is to conduct a subsequent visit and deliver the findings pertaining to the above-mentioned allegations. An initial 10-Day visit was conducted by LPA Jeremiah Randle on 01/19/23 with Executive Director/Administrator (S1: Julius Osorio). During this visit, LPA conducted a tour of the facility’s physical plant and observed the residents in care for health and safety purposes. A separate investigation was conducted by the Department’s Investigation Bureau by Investigator (Dennis Seng) which included medical records review; interviews with hospital personnel, local law enforcement, Fire/EMT personnel, and facility sthe state’s words, verbatim · CDSS document, Jan 27, 2024 · control 11-AS-20230117153703

Allegation investigated: Facility staff did not issue a proper refund.

On 11/15/23 Licensing program analyst (LPA) Lizeth Villegas conducted a subsequent complaint visit to render investigation finding. LPA met with Memory Care Director Grace Farwell as the purpose of today’s visit was explained. The investigation consisted of the following: On 09/15/23 LPA interviewed Executive Director (ED) via telephone, staff #1-5 (S1-S5), and residents # 2-8 (R2-R8). On 08/17/23 Licensing Program Analyst (LPA) Dabuet met with Regional Operations Specialist Matthew Ryan and conducted Interviews with Regional Operation Specialist and Business Office Director, obtained documents for resident #1 (R1) including Residence and Services Agreement, Resident Invoice, other pertinent documents associated with this complaint, and a copy of the staff and resident roster. The investigation revealed the following: Allegation: Facility staff did not issue a proper refund. Substantiatedthe state’s words, verbatim · CDSS document, Nov 15, 2023 · control 11-AS-20230810151938