Oakmont Of Orange

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: Facility did not respond to a resident's call light in a timely manner Facility did not call medical services in a timely manner

An unannounced Complaint Investigation was conducted on this day by Licensing Program Analyst (LPA) Claudia Gutierrez for the purpose of delivering findings. LPA met with Executive Director (ED) Dennis Robeniol and explained the purpose of the inspection. Regarding allegations, Facility did not respond to a resident's call light in a timely manner and Facility did not call medical services in a timely manner, the following was revealed: It is alleged facility staff did not respond to Resident 1’s (R1’s) call light in a timely manner or call medical services for R1 in a timely manner. During the course of the investigation, LPA obtained a copy of Charting Notes for R1 signed by Staff 1 (S1) which indicated that on October 16, 2025 at 4:00 a.m., R1 had an unwitnessed fall while walking to the restroom and hit their head. Per Charting Notes, R1 pressed their bathroom alarm but cleared themselves while they kept pressing on it. Charting Notes do not specify the time lapse between R1’s fallthe state’s words, verbatim · CDSS document, Jun 4, 2026 · control 22-AS-20260114075555

Allegation investigated: Facility staff did not assist resident with incontinence care as needed. Facility staff did not assist resident with showering as needed. Facility staff handled the resident in a rough manner.

On May 28, 2026, Licensing Program Analyst (LPA) Jessica Cho made an unannounced visit for the purpose of concluding the investigation into the above allegations. LPA met with Health Services Director (HSD) Angela Boyd and stated the reason for the visit. During the course of the investigation, the Department toured the facility, interviewed eight residents, three staff, and obtained documentation for review: Resident Rosters, Personnel Rosters, Face Sheets, Physician's Reports, Individualized Service Plans, and Resident Care Notes. The investigation is as follows: On June 25, 2024, the Department received the complaint. The investigation was initiated by LPA Jenifer Tirre on July 3, 2024. LPA Tirre toured the physical plant of the facility including resident rooms. LPA Cho continued the investigation on today's date, conducted interviews, and review of records. Regarding the allegation, Facility staff did not assist resident with incontinence care as needed, it is alleged that Residenthe state’s words, verbatim · CDSS document, May 28, 2026 · control 22-AS-20240625085618

Allegation investigated: Resident sustained multiple falls while in care due to staff neglect

An unannounced Complaint Investigation was conducted on this day by Licensing Program Analyst (LPA) Claudia Gutierrez for the purpose of delivering findings. LPA met with Executive Director (ED) Dennis Robeniol and explained the purpose of the inspection. Complaint alleges Resident 1 (R1) sustained multiple falls while in care due to staff neglect. During the course of the investigation, interviews were conducted with R1, one witness, and two staff. During their interview, R1’s responsible party, Witness 1 (W1), was unable to confirm or deny if R1 had sustained multiple falls due to staff neglect. Per W1, R1 may have sustained a fall in May 2024 and October 2024, however, stated they could not recall any of the details regarding the falls. W1 stated that per R1's Care Plan, staff should be conducting routine checks, which consist of staff checking on R1 on a regular basis and reporting back to W1 in the event of a fall. (Cont. LIC9099-C) Unsubstantiatedthe state’s words, verbatim · CDSS document, May 21, 2026 · control 22-AS-20241010090602

Allegation investigated: Staff did not prevent resident from smoking in the facility

An unannounced Complaint Investigation was conducted on this day by Licensing Program Analyst (LPA) Claudia Gutierrez for the purpose of delivering findings. LPA met with Executive Director (ED) Dennis Robeniol and explained the purpose of the inspection. Complaint alleges Staff did not prevent Resident 1 (R1) from smoking in the facility. During the course of the investigation, interviews were conducted with ten facility residents, including R1, and four staff. During their interview, R1 stated that upon their admission to the facility on March 31, 2026, they had smoked a cigarette in their bedroom on two occasions. Per R1, they were immediately informed by Staff 1 (S1) they could not smoke in their room and that a designated smoking area was available outside. R1 denied smoking inside the facility since being informed they could not smoke inside and stated they have since quit smoking. During their interview, S1 stated they had not personally witnessed R1 smoking inside, however, thethe state’s words, verbatim · CDSS document, May 21, 2026 · control 22-AS-20260515103726

Allegation investigated: Resident sustained multiple falls while in care Staff neglected resident while in care

Licensing Program Analyst (LPA) Jenifer Tirre conducted an unannounced visit to deliver findings on an investigation. LPA was greeted and granted entry into the facility by staff and explained the reason of the visit with Executive Director Dennis Robeniol During course of the investigation, the Department reviewed & obtained records including Physician’s report, fall risk evaluation assessment, Resident assessment, charting notes, hospital records and service plan. Department also interviewed staff and witness. The investigation revealed the following regarding allegations: Resident sustained multiple falls while in care and Staff neglected resident while in care: Regarding Resident sustained multiple falls while in care: Based on resident records, Resident was fully independent of mobility back on 5/29/2020 upon admission to facility. R1 had a Fall Risk Evaluation assessment back on 3/22/22 where resident scored 8 indicating high risk of falling. At the time service plan interventionthe state’s words, verbatim · CDSS document, May 18, 2026 · control 22-AS-20230706083051

Allegation investigated: Facility staff did not provide adequate supervision resulting in resident being injured.

An unannounced Complaint Investigation was conducted on this day by Licensing Program Analyst (LPA) Claudia Gutierrez for the purpose of delivering findings. LPA met with Executive Director (ED) Dennis Robeniol and explained the purpose of the inspection. Complaint alleges Staff did not check on Resident 1 (R1) for approximately two hours, resulting in R1 sustaining a fall and being injured. During the course of the investigation, LPA obtained a copy of Resident Care Notes for R1 signed by Staff 1 (S1) which indicated that on June 27, 2024, R1 had been found on the floor by their bed with lacerations by their right eye and skin tear to right wrist, 911 was called, and R1 was transported to the hospital. The Care Notes, however, do not specify if there was a lapse in time between R1’s fall and R1 being found, and do not indicate the time R1 was last checked on by staff prior to being found on the floor. R1 could not be interviewed due to their passing on July 10, 2024. (Cont. LIC9099-C)the state’s words, verbatim · CDSS document, May 14, 2026 · control 22-AS-20240709164259

Allegation investigated: Staff did not seek timely medical care for resident in care

An unannounced Complaint Investigation was conducted on this day by Licensing Program Analyst (LPA) Claudia Gutierrez for the purpose of delivering findings. LPA met with Executive Director (ED) Dennis Robeniol and explained the purpose of the inspection. Complaint alleges Staff did not seek timely medical care for Resident 1 (R1). During the course of the investigation, LPA obtained a copy of Charting Notes indicated that on November 26, 2024 at approximately 12 p.m., R1 had reported pain to left hip and leg and was unable to bare any weight on their left leg. An ambulance was called and arrived at approximately 12:15 p.m. to transport R1 to the hospital. Interviews were conducted with one witness and eight facility residents, including R1. During their interview, R1 was unable to confirm or deny the allegation. During their interview, R1’s responsible party, Witness 1 (W1), stated that on the morning of November 26, 2024, they received a call from a staff member who informed them R1the state’s words, verbatim · CDSS document, May 14, 2026 · control 22-AS-20241126135236

Allegation investigated: Staff did not follow physician's order to monitor resident's blood pressure Staff falsified resident records

An unannounced complaint investigation was conducted on this day by Licensing Program Analyst (LPA) Claudia Gutierrez regarding the allegations mentioned above. LPA met with Executive Director (ED) Dennis Robeniol and Health Services Director (HSD) Angela Boyd. Regarding the allegation, Staff did not follow physician's order to monitor resident's blood pressure, the following was revealed: It is alleged that Staff did not follow physician's order to monitor Resident 1’s (R1’s) blood pressure. An interview was conducted with R1’s responsible party, Witness 1 (W1), who stated that the facility had informed them they could not accept a verbal request to monitor R1’s blood pressure. Per W1, on January 13, 2026, they provided a printout of the physician’s order, which also had a medical stamp with R1’s care provider information, however, the facility would still not accept it and stated physician’s hand signature was required. Per W1, they were then provided with the incorrect fax number fothe state’s words, verbatim · CDSS document, Apr 22, 2026 · control 22-AS-20260114213328

Allegation investigated: Staff mismanaged resident's medications. Staff did not respond to resident's call button in a timely manner.

On April 1, 2026, Licensing Program Analyst (LPA) Brandon Lopez made an unannouned visit to the facility to continue the investigation into the allegations listed above and to deliver the complaint findings. LPA was greeted and granted entry into the facility by staff after explaining the purpose for the visit. Health Services Director Angela Boyd was present and assisted on today's visit. During the course of the investigation, LPA conducted seven resident interviews, six staff interviews, reviewed and collected pertinent documents for this complaint. Regarding the allegation, staff mismanaged resident's medications, the following has been concluded: It was alleged that staff mismanaged Resident #1 (R1) medication on September 2023, April 2025, and August 2025. LPA reviewed the medication administration records for R1 for September 2023, April 2025, and August 2025. LPA observed that the facility did not provide R1 her presribed Vitamin D3 medication on September 13, 2023, due to thethe state’s words, verbatim · CDSS document, Apr 1, 2026 · control 22-AS-20260122100814

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: Licensee is not ensuring that resident has the ability to make and receive confidential phone calls.

An unannounced Complaint Investigation was conducted on this day by Licensing Program Analyst (LPA) Claudia Gutierrez. LPA met with Executive Director (ED) Anna Pastores and Health Services Director (HSD) Alyson Womack and discussed the purpose of the inspection. Regarding the allegation, Licensee is not ensuring that resident has the ability to make and receive confidential phone calls, the following was revealed: It is alleged R1 does not have the ability to make and receive confidential phone calls. During the course of the investigation, interviews were conducted with R1, six additional facility residents, and two staff. During their interview, R1 stated they are able to make and receive and make private phone calls, however, was unable to indicate how the phone calls are made or received. During their interview, six of six additional facility residents stated they are able to make and receive private phone calls from their respective bedroom, using a landline or a personal cell phthe state’s words, verbatim · CDSS document, Nov 19, 2025 · control 22-AS-20251114161246

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: Caregiver was rough with resident resulting in bruising

Licensing Program Analyst (LPA) Cheyenne Ratajczak arrived at the facility unannounced and met with Health Services Director (HSD) Alyson Womack to deliver findings for the above complaint allegations. The department conducted interviews with facility staff, resident and a facility observation was done to investigate this allegation. Interviews with staff indicated there had been no witnessed issues with staff members handling residents in a rough manner. Interviews indicated Resident #1 (R1) did bruise/discolor easily. During LPA visit on 07/14/2025 LPA observed staff to be engaging with residents and assisting residents in an appropriate manner. LPA was unable to obtain any additional information as the caregiver and resident are no longer at the facility. Based upon the information obtained during investigation, the above allegation is unsubstantiated. A finding that the complaint is UNSUBSTANTIATED means that although the allegation may have happened or is valid, there is not a prethe state’s words, verbatim · CDSS document, Jul 14, 2025 · control 22-AS-20221122101417

Allegation investigated: Resident sustained fractures while in care due to neglect. Staff failed to seek resident medical attention in a timely manner. Insufficient staffing to meet residents' needs. Staff failed to respond to resident's call assistance button in a timely manner.

Licensing Program Analyst (LPA) Cheyenne Ratajczak arrived at the facility unannounced and met with Health Services Director (HSD) Alyson Womack to deliver findings for the above complaint allegations. During the investigation, the department conducted interviews and reviewed documentation pertinent to the investigation. The results of the investigation are as follows: ***Report continued on 9099-C*** Unsubstantiatedthe state’s words, verbatim · CDSS document, Jul 14, 2025 · control 22-AS-20230130113643

Allegation investigated: Facility staff refused to assist resident with toileting and changing

Licensing Program Analyst (LPA) Cheyenne Ratajczak arrived at the facility unannounced and met with Health Services Director (HSD) Alyson Womack to deliver findings for the above complaint allegations. The department conducted interviews with facility staff and residents. Interviews with residents revealed they feel like staff come when they call for assistance but it can take a while. Interview with staff revelaed that staff will assist in changing the resident and cleaning up the area. LPA was unable to interview involved staff as this complaint was made in March of 2023. Based upon the information obtained during investigation, the above allegation is unsubstantiated. A finding that the complaint is UNSUBSTANTIATED means that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. Exit interview conducted a copy of the report and appeal rights were left at the facility. Unsubstantiatedthe state’s words, verbatim · CDSS document, Jul 14, 2025 · control 22-AS-20230301143239

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 is not getting proper nutrition. Staff failed to provide care and supervision.

An unannounced Complaint Investigation was conducted on this day by Licensing Program Analyst (LPA) Claudia Gutierrez regarding the allegations mentioned above and for the purpose of delivering findings. LPA met with Wellness Director (WD) Alyson Caluza and explained the purpose of the inspection. Interviews were conducted with six facility staff and five residents regarding allegation resident is not getting proper nutrition. Interviews conducted with six out six staff could not corroborate this allegation, as all staff interviewed acknowledged R1 was on a special diet and reported assisting him as needed at mealtimes. Interviews conducted with five out of five residents also could not corroborate allegation. Four out of five residents reported no complaints regarding facility food or nutrition and stated they received sufficient food in quantity. One out of five residents was unable to confirm or deny allegation. Per Physician’s Fax report dated 5/04/22 facility reported to R1’s Physthe state’s words, verbatim · CDSS document, Dec 18, 2023 · control 22-AS-20220705155653

Allegation investigated: Staff did not safeguard resident's personal property. Resident sustained bruising while in care.

On this day, Licensing Program Analyst (LPA) Kevin Saborit-Guasch made an unannounced visit to the facility for the purpose of delivering findings into the investigation of the two allegations listed above. LPA was greeted and granted entry by front desk staff after introducing himself and stating the purpose of the visit. Executive Director Anna Pastores was notified and present during the visit. The initial complaint investigation was conducted on November 6, 2023. Records for resident R1, including the admission agreement and a waiver to inventory personal property upon admission were reviewed. LPA verified the required posting of the facility's theft and loss policy and reviewed the theft and loss log maintained by facility staff at the front desk. Documentation of staff training on theft and loss was also provided. One staff interview, one witness interview and one resident interview were also conducted during the visit. CONTINUED ON LIC9099-C Unsubstantiatedthe state’s words, verbatim · CDSS document, Dec 7, 2023 · control 22-AS-20231101104331

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.