Oakmont of Burlingame

Allegation investigated: Facility staff did not provide a full refund upon resident’s death Facility staff do not respond to authorized representative

On July 15, 2026, Licensing Program Analyst (LPA) Murial Han conducted an unannounced visit to delivery the complaint investigation findings. LPA met with the administrator and LPA explained the purpose of today's visit. Regarding allegation of - facility staff did not provide a full refund upon resident’s death, the reporting party stated that resident #1 (R1) passed away in the beginning of March and R1’s room was cleaned and inspected by a facility staff 2 days later, however, the facility did not refund the remaining March payment when this allegation was made. As part of the investigation, LPA interviewed the administrator and reviewed documents. During LPA’s visit on 5/28/2026, LPA interviewed the administrator who presented the refund checks of R1 to LPA and stated that the checks were cut on 3/17/2026 and the facility attempted to call the responsible party and ask for a form of mail that he/she preferred but there was no answer so the checks were not mailed. The administrator did not remember who and when the calls were made. Substantiated On June 12, 2026, the administrator provided a copy of the facility phone call logs for the month of March, and it revealed that three calls were made to the responsible party, however, those calls were made before the refund checks were cut. Therefore, the facility could not prove that R1's responsible party was notified of the refund checks. Based on the admission agreement, it stated that in the event of the death of a resident, the community shall refund any fees paid in advance covering the time after the removal of deceased resident’s personal property from the suite to the individual(s) or entity contractually responsible for the fees, or as applicable, the resident’s estate, within fifteen (15) days following the removal of the deceased resident’s personal property. After the investigation, this allegation is substantiated as during LPA's visit on 5/28/2026, LPA observed the refund checks were at the facility and the facility could not prove that R1's responsible party was notified of the refund checks. Regarding the allegation of - facility staff do not respond to authorized representative, the reporting party stated that in January 2026, R1’s responsible party provided a letter to the administrator inquiring about R1’s monthly rent and care increase. However, they did not get any response back from the facility. As part of the investigation, LPA interviewed the administrator who acknowledged that the letter was received on January 2, 2026 and the administrator had a verbal conversation with the Regional Director about it but did not get any responses back. Therefore, there was no follow-up provided to R1’s responsible party. After the investigation, this allegation is substantiated. Based on interviews, record reviews, and observations during the investigation, the preponderance of evidence standard has been met. Therefore, this allegation was determined to be substantiated. Deficiencies of the California Code of Regulations, Title, 22 cited on the LIC9099-D. Failure to correct the deficiencies may result in civil penalties. This report is reviewed and discussed with the administrator; a copy is provided with Appeal Rights provided.the state’s words, verbatim · CDSS document, Jul 15, 2026 · control 14-AS-20260522134204

From the deficiency page — Deficiency type: Type B · Section cited: HSC 1569.652(c) · Plan of correction due date: Jul 24, 2026

§1569.652 Termination of admission agreement upon death of resident; removal of resident’s property; refund of fees paid; notice of contract termination and refunds(c)A refund of any fees paid in advance..within 15 days after the personal property is removed. This requirement is not met as evidenced by based on record reviews, interviews and observation, R1 passed away in the begining of March 2026 and all of R1's personal property was removed 2 days later and as of May 2026 which poses a potential health and safety risks to residents in care.the state’s words, verbatim · CDSS document, Jul 15, 2026

Plan of correction: During today's visit, the administrator stated that they are in communication with R1's RP regarding the checks. The administrator will develop a plan to ensure facility is in compliance with resident refunds. The administrator will provide a copy of the plan to CCL by 7/24/2026.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.1(a)(9) · Plan of correction due date: Jul 22, 2026

87468.1Personal Rights of Residents in All Facilities(a) Residents in all residential care facilities for the elderly shall have all of the following personal rights:(9) To have communications to the licensee from their representatives answered promptly and appropriately This requirement is not met as evidenced by based on record reviews, interviews and observations, R1's responsible party provided a letter to administrator inquiring about R1's monthly payment but did not get answered promptly which posed a potential health and safety risks to residents in care.the state’s words, verbatim · CDSS document, Jul 15, 2026

Plan of correction: The administrator will develop a plan of correction to ensure resident's representatives inquires are answered promptly and appropriately. The administrator will provide a copy of the plan of correction to CCL by 7/25/2026.

Type of visit: Required - 1 Year

On July 15, 2026, Licensing Program Analyst (LPA) Murial Han conducted an unannounced annual inspection. LPA met with Administrator, Janna O'Sullivan and explained the purpose of the visit. LPA toured facility and grounds with the administrator. No accessible bodies of water or fire safety hazards observed. This is a 4 story facility; Assisted Living (AL) on the first and second floor and Memory Care (MC) on the third and fourth floor. LPA toured the facility common areas, resident rooms, activity space, outdoor areas and kitchen area. A comfortable temperature of 76 degrees is maintained in the facility and lighting is sufficient for comfort. Hot water temperature measured between 110-116 degrees F in the kitchen, and resident rooms . Overall facility was in clean, odor-free and free from any tripping hazards. Resident rooms and bathrooms observed had all required furnishings, and grab bars and built-in non-skid mats in each bathroom. LPA toured the kitchen and observed 2 days for perishables and 7 days non-perishable. LPA observed the 3 garbage cans in the kitchen have dried brown, black, white and yellow spots and particles on the outside. LPA observed medications, sharps and chemicals were locked and inaccessible to residents and there is a medication cart on each floor. Emergency and disaster drills were reviewed to be adequate. A review of (5) resident files was conducted and noted on LIC 858. A review of (5) staff files was conducted and noted on LIC 859. The administrator will provide a copy of the administrator certificate to CCL by 7/17/2026. Based on observation, deficiency is cited under California Code of Regulations, Title, 22 cited on the LIC 809D. Failure to correct the deficiencies may result in additional civil penalties. This report is reviewed and discussed with administrator. A copy of this report and the appeal rights were provided.the state’s words, verbatim · CDSS document, Jul 15, 2026

Type of visit: Case Management - Other

On April 30, 2026, Licensing Program Analyst (LPA) Murial Han conducted an unannounced Case Management visit to deliver the findings of an investigation that was conducted by the department. LPA met with administrator and explained the purpose of today's visit. On December 1, 2025, the facility submitted an incident report and a death report regarding resident #1 (R1) who fell under the care and supervision of the facility and subsequently passed away a few days later at the hospital. Based on information from interviews conducted with staff and records reviewed, the investigation is concluded with a finding of unsubstantiated. No deficiencies were cited today. This report was reviewed with the administrator and a copy of this report is provided.the state’s words, verbatim · CDSS document, Apr 30, 2026

Type of visit: Case Management - Incident

On April 30, 2026, Licensing Program Analyst (LPA) Murial Han conducted an unannounced case management visit to follow up on an incident that was reported by the facility. LPA met with the administrator and explained the purpose of today's visit. On April 27, 2026, the facility reported that on April 22, 2026, during lunch, staff witnessed resident #1 (R1) grabbed resident #2 (R2)'s lunch and R2 attempted to stop R1 and threw water and juice at R1. The incident report states that staff were able to redirect both residents and calm them down. During today's visit, LPA interviewed staff, interviewed R1, observed R2, and reviewed documentation. According to S1 who witnessed the incident stated that both residents were separated immediately and there was no injuries noted to both residents. In addition, S1 and staff #2 (S2) stated that since the incident, they are monitoring both residents more closely during mealtimes and there were no other incidents occurred. According to the Regional Memory Care Director, R1 and R2 continued to sit together during lunch as their preference, and they tried different methods to have them sit separately but they refused. Therefore, facility staff continued to monitor them closely. LPA interviewed R1 who appeared to be pleasant and did not remember the incident. LPA attempted to interview R2 but R2 was sleeping in the room. Based on documentation, R1 and R2 did not sustain any injuries due to the altercation. No deficient is cited. This report is reviewed and discussed with the administrator and a copy is provided.the state’s words, verbatim · CDSS document, Apr 30, 2026

Type of visit: Required - 1 Year

On July 15, 2025, Licensing Program Analyst (LPA) Komal Charitra conducted an unannounced annual inspection. LPA met with Executive Director, Janna O'Sullivan and explained the purpose of the visit. LPA toured facility and grounds. No accessible bodies of water or fire safety hazards observed. This is a 4 story facility; Assisted Living (AL) on the first and second floor and Memory Care (MC) on the third and fourth floor. LPA toured the facility including but not limited to a random sample of resident rooms on each floor, common areas, and kitchen area. LPA observed some residents doing activities with staff or walking around at the facility. A comfortable temperature of 74 degrees is maintained in the facility and lighting is sufficient for comfort. Hot water temperature measured between 107-113 degrees F throughout the facility. Overall facility was in clean, odor-free and free from any tripping hazards. Resident rooms and bathrooms observed had all required furnishings, and grab bars and built-in non-skid mats in each bathroom. LPA toured kitchen and observed 2 days for perishables and and 7 days non-perishable. Medications, sharps and chemicals were locked and inaccessible to residents. Emergency drill are being conducted and logged every 3 months. Carbon monoxide monitors are working properly. All fire extinguishers have been checked and current as of January 2025. First aid kits were observed present and complete. Five resident records and five staff records were reviewed. Resident records are updated, complete and signed. Staff records are complete, with training logs that have met the basic requirement. Medication review was done, and all medications are accounted for, and centrally stored medication records are updated. No citations are issued during the visit. Report is reviewed with the administrator and a copy is provided.the state’s words, verbatim · CDSS document, Jul 15, 2025

Type of visit: Case Management - Deficiencies

On June 18, 2025, Licensing Program Analyst (LPA) Murial Han conducted an unannounced Case Management Visit to follow up on an incident that was reported by the facility. LPA met with Director of Sales, Anotonio Leon and Health Services Director, Cathy Nugyen and LPA explained the purpose of today's visit. On My 27, 2025, the facility reported that resident #1 (R1) who resides in the Memory Care was escorted to the first floor for a holiday celebration and at 4:03PM, the caregiver who was providing supervision to R1 had to step away to assist another resident resulting R1 leaving the facility unassisted. At 4:10pm, the Engagement Director saw R1 outside of the community and was escorted by to the facility. On June 5, 2025, Licensing Program Analyst (LPA) conducted a Case Management visit and interviewed facility director and collected documents. According to the facility director, the caregiver who was supervising R1 was also providing supervision to 2 other residents and one of them needed to go to the bathroom so the caregiver took the resident to the bathroom and did not endorse it to anyone else to watch R1, therefore, R1 left the facility unattended. The facility director acknowledged that the front door should have been closed at all times but there were a lot of foot traffic due a holiday celebration so R1 most likely got out from that door. Based on the documents provided by the facility, R1 has a diagnosis of moderate late onset Alzheimer's Dementia, not able to leave the facility unattended and wanders into exit doors and needs redirection. Based on the above observation, deficient is cited under California Health and Safety Code on the LIC 809D. Failure to correct the deficiencies may result in civil penalties. Report was discussed and reviewed with the directors. A copy of this report and the Appeal Rights was provided.the state’s words, verbatim · CDSS document, Jun 18, 2025

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87705(d) · Plan of correction due date: Jun 19, 2025

87705 Care of Persons with Dementia (d) The licensee shall ensure that the facility has an auditory device or other staff alert feature to monitor exits on exterior doors and... This requirement is not met as evidenced by based on observation, interview and record review, R1 resides in the Memory Care and was escorted to the first floor for a holiday celebration and exit the facility unattended which poses an immediately health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Jun 18, 2025

Plan of correction: The administrator/licensee will develop a plan to ensure there is a staff alert feature to monitor exits on exterior doors when the auditor device was not activated and will submit a copy of the plan to CCL by 6/19/2025. The plan shall indicate staff training.

Type of visit: Case Management - Incident

On June 5, 2025, Licensing Program Analyst (LPA) Murial Han conducted an unannounced Case Management visit to follow- up on an incident that was reported by the facility. LPA met with the administrator and explained the purpose of the visit. On May 27, 2025, the facility reported to CCL that on May 26, 2025, at 3:05PM, resident #1 (R1) who resides in Memory Care Unit was brought to the first floor for a celebration and at 4:03PM, caregiver went to assist another resident and at 4:10PM, R1 was seen by the Engagement Director outside of the facility and R1 was escorted back to the facility. During today’s visit, LPA observed R1, interviewed the administrator and requested for documents to be submitted by 6/6/2025. No deficiency is cited today. This report is reviewed and discussed with the administrator. A copy is provided.the state’s words, verbatim · CDSS document, Jun 5, 2025

Allegation investigated: Resident was locked in a room due to staff neglect

On March 12, 2025, Licensing Program Analyst (LPA) Murial Han conducted an unannounced complaint visit to deliver the investigation outcome. LPA met with the administrator and explained the purpose to today's visit. Regarding to the allegation of – resident was locked in a room due to staff neglect, the reporting party stated that resident – in – question (R1) resides on the memory care unit and the responsible party was notified by the facility that R1 was missing. The reporting party reported that after hours of searching, R1 was found in an empty room that was locked, and facility staff was not able to check that room because the door lock was broken. The reporting party also stated that the empty room was next to R1's room and he/she wandered into that room, shut the door and was not able to get out due to the broken lock. The reporting party stated that the facility did not search room to room resulting R1 being stuck in an empty room for hours. Substantiated As part of the investigation, LPA interviewed the administrator, the maintenance director, and the resident care coordinator. According to the administrator, she was notified at 5pm that R1 was missing, the facility immediately conducted a search inside and outside of the facility, viewed the camera footage, reported it to the local police department where a silver alert was activated, and reported it to R1’s responsible party. The administrator stated that R1 was found in a locked empty room that was next to R1’s room and the room was being prepared by the maintenance staff for new admission. The administrator stated that when a room is being prepared for new admissions, it should be closed when it’s not being worked on to avoid residents entering it. The administrator acknowledged that R1 would have been found a lot sooner had the staff search all the rooms on the 3rd floor. LPA interviewed the maintenance director who stated that the day prior to the incident, he was getting the room ready for new admission and after painting the room, he realized that the door lock was broken but it was too late to bring it to the shop and fix it, so he left it open instead of closing it. According to the maintenance director, this was not endorsed to facility staff resulting staff was unaware that the empty room was open and R1 wandered inside, shut the door as the room was next to R1's room. LPA interviewed the resident care coordinator who validated the information above and stated that R1 has a tendency of shutting the door after entering his/he room. Therefore, R1 mistakenly entered the empty room, shut the door and was not able to open it back up because of the broken lock. Based on the documents provided by the facility, the Elopement /Missing Resident Policy 404 indicated that upon the discovery that a resident is thought to be missing, community team members will activate and follow the Missing Resident- Immediate Action Plan Form 405a and on the Form 405a, it indicated that within 5-10 minutes, assign staff to search unit. After the investigation, this allegation is substantiated as the staff did not followed the protocols on the Action Plan Form 405a and search the unit/room on the floor and the director failed to endorse to staff that the empty room was left open resulting R1 being locked in a room with a broken door for many hours. Based on interviews, and observations during the investigation, the preponderance of evidence standard has been met. Therefore, this allegation was determined to be substantiated. Deficiencies of the California Code of Regulations, Title, 22 cited on the LIC9099-D. Failure to correct the deficiencies may result in civil penalties. Report was discussed with the administrator; a copy is provided with Appeal Rights provided.the state’s words, verbatim · CDSS document, Mar 12, 2025 · control 14-AS-20250121124939

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87468.1(a)(2) · Plan of correction due date: Mar 13, 2025

87468.1 Personal Rights of Residents in All Facilities (a) Residents in all residential care facilities for the elderly shall have all of the following personal rights:(2) To be accorded safe, healthful and comfortable...This requirement is not met as evidenced by based on interviews, record reviews and observations, staff did not follow the facility's missing resident search protocol to search all the rooms/units when R1 was discovered missing and staff was unaware of a broken door lock resulting R1 being in a locked empty room for hours which poses an immediately health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Mar 12, 2025

Plan of correction: The administrator/Licensee will provide a plan to prevent this from happening again and the plan shall include staff training. The administrator/licensee will provide a copy of the plan to CCL by 3/13/2025.

Type of visit: Prelicensing

On 6/27/2024 LPA Grace Donato made an unannounced pre-licensing visit to the facility. LPA met with Executive Director, Oreisha Morgan. LPA explained the purpose of the visit. LPA toured the facility including random resident rooms, common areas & kitchen. The passageways were free of obstruction. Residents currently engaged in different activities. The residents have adequate amount of linens and all personal belongings are intact. While touring the facility it was observed that the room temperature was at 72 deg F. Hot water was also tested in the bathrooms and the temperature was 110 deg F. Carbon monoxide monitor is working properly. All fire extinguishers are scheduled for maintenance on 7/5/2024. Additional evacuation chairs in stairwells will be added. Client bathrooms were observed to be in good repair equipped with grab bars and non-skid floors. LPA checked the food supply and there is adequate amount of food, 2 days for perishables and & 7 days non-perishable. Medication is audited monthly by the Resident Care Director. Five client records and five staff records were reviewed. Resident records are updated, complete and signed. Staff records are complete, with training logs. Facility is clean and in good repair based on observations made today. Facility is in compliance with Title 22 regulations. No citations are issued. Component III is conducted on this day. No deficiencies are cited at this time. Report is reviewed and a copy is provided.the state’s words, verbatim · CDSS document, Jun 27, 2024