Oakmont Gardens

Licensing Program Analyst (LPA) Christi Coppo arrived at this facility unannounced, to open an investigation into the above allegations. Complaint alleges staff did not respond to resident's request for assistance in a timely manner. Complainant states that resident (R1) waited for more than thirty [30] minutes after pushing their pendant before staff responded to pendant call. During investigation, LPA reviewed facility's pendant call log. Call log review shows that on 7/1/25 R1 waited 17 minutes after pressing their pendant before receiveing assistance, on 7/4/25 they waited 33 minutes, in the afternoon on 7/6/25 they waited 19.5 minutes, and in the evening on 7/6/25 they waited 15 minutes. During investigation, LPA reviewed facility's call light/pendant procedure policy. Policy states that all pendant calls will be answered promptly. Policy further states that "promptness is essential, as a resident may be alone and in an emergency situation." Continued on 9099C... SubstantiatedRead the full finding— CDSS inspection report, July 17, 2025 · control 21-AS-20250714151540

Licensing Program Analyst (LPA) Christi Coppo arrived at this facility unannounced, to open an investigation into the above allegations. Complaint alleges facility water was turned off, resulting in residents not provided drinking water or water for toilets and bathing. On 5/12/25 LPA was notified that a water pipe at the facility had broken and the water was shut off as of Sunday 5/11/25 from 11:00am onward and was attempted to be repaired. Facility turned the water back on Monday 5/12/25 at 10:30am, but the repair fix did not work and the repair burst. So, the water was again shut off for the entire facility. Facility did not notify CCL of water being shut off. On 5/12/25, upon learning of the incident, LPA immediately contacted facility Administrator Mark Strohschein to inquire as to status of water at facility and if they had engaged their Emergency Disaster Plan. On 5/12/25 at 2:38pm Admin responded to LPA, confirming the water had been turned off due to a Continued on 9099C... SuRead the full finding— CDSS inspection report, June 10, 2025 · control 21-AS-20250604125611

At approximately 12:45PM, Licensing Program Analyst (LPA) Christi Coppo arrived at this facility unannounced, to deliver finding for above allegation. LPA met with Administrator Morgan Holien. Complaint alleges facility not maintained in safe condition for residents. Complainant states that the sidewalk concrete on the corner of the west entrance by WellsFargo is cracked and raised, presenting a safety hazard for residents. Complaintant states that the sidewalk concrete behind apartments #124-126 is also cracked and raised, presenting a safety hazard for residents. Complainant states that repairs to these areas have not been completed because the facility does not have enough money in their budget to fix them. During investigation, LPA contacted the City of Santa Rosa Public Works Department to determine the party responsible for the repairs, LPA was advised that private property owners are responsible for sidewalk repairs Continued on 9099C... UnsubstantiatedRead the full finding— CDSS inspection report, November 7, 2024 · control 21-AS-20241031093432

Licensing Program Analyst Leibert arrives unannounced for the purpose of delivering findings on this complaint. Complainant alleges that staff made errors regarding resident's (R1) medications and that R1 was not provided timely medical attention following a fall on 10/31/2023. Through investigative interviews and review of pertinent documents, the following determinations are made: The specific medications and dates of alleged errors were not reported to CCL; Health Services Director states that any medications not given were due to R1's absence from the facility; Facility reports that R1 initially indicated a lack of pain and declined medical treatment following R1's fall; Staff reportedly checked R1 daily for changes in gait and pain; R1 was sent out for medical treatment on day three when R1 reported pain and requested treatment; Facility's Report of Injury (LIC624) conforms with staff statements regarding the accident. Although allegations may be true, based upon the statements maRead the full finding— CDSS inspection report, December 19, 2023 · control 21-AS-20231113084830

Licensing Program Analyst (LPA) Christi Coppo and Licensing Program Manager (LPM) Victoria Bertozzi arrived unannounced to conduct a complaint investigation. Staff did not respond to a resident's call button in a timely manner - Complaint alleges that resident fell and pushed thier call button for assistance but a caregiver did not respond in a timely manner. Per LPA review of call button log, there was at least one incident where there was a 94 minute delay following a resident fall. LPA and facility staff discussed areas of concern regarding the call button system and LPA will continue to work with facility to ensure resident safety. Based on record review(s), the preponderance of evidence standard has been met, therefore the above allegation(s) are found to be SUBSTANTIATED. California Code of Regulations, (Title 22, Division & Chapter number), are being cited on the attached LIC 9099D. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may resultRead the full finding— CDSS inspection report, December 12, 2023 · control 21-AS-20231206151404

Licensing Program Analyst (LPA), Farhaan Sarangi arrived unannounced at Oakmont Gardens for the purpose of delivering complaint findings. LPA was greeted by Administrator, Morgan Holien, and was granted access into the facility. During the course of the investigation, LPA reviewed resident(s) records, facility records, interviewed staff, residents and outside agency staff. Complaint alleges Facility staff left resident in soiled clothing for a prolonged period of time and Facility staff do not properly assist resident with toileting needs. Based on interviews that were conducted, LPA could not prove or disprove the allegations. Furthermore, while interviewing a random sample of residents in care, LPA learned of no concerns with the care that the facility provides. On July 26, 2023 and July 27, 2023, LPA interviewed an outside agency which yielded inconsistent statements as it relates to the allegations in question. (Report continued on LIC 9099C) UnsubstantiatedRead the full finding— CDSS inspection report, July 31, 2023 · control 21-AS-20230519161049

Licensing Program Analyst (LPA), Farhaan Sarangi arrived unannounced at Oakmont Gardens for the purpose of touring Resident #1's room and delivering complaint findings. LPA was greeted at the door by Administrator, Morgan Holien and was granted access into the facility. During the course of the investigation, LPA conducted a tour of the facility on July 6, 2023, made observations, interviewed Resident #1 and Administrator. Complaint alleges that facility staff did not ensure that passageways are kept free from obstruction. Based on interviews that were conducted, LPA was made aware that a new ramp was on order and was installed recently. During the tour of Resident #1's room conducted on July 6, 2023, LPA observed a ramp for entrance and exit to the patio. LPA learned that Resident #1 was content with the ramp and the placement of the ramp. (Report continued on LIC 9099C) UnsubstantiatedRead the full finding— CDSS inspection report, July 6, 2023 · control 21-AS-20230525101426

"AMENDED" This is an amended version of the original report created on July 6, 2023-SEE BELOW. Licensing Program Analyst (LPA), Farhaan Sarangi arrived unannounced at Oakmont Gardens for the purpose of touring the facility and delivering complaint findings. LPA was greeted at the door by Administrator, Morgan Holien and was granted access into the facility. During the course of the investigation, LPA conducted a tour of the facility on July 6, 2023, made observations, interviewed staff and residents. Complaint alleges that Staff do not ensure residents are accorded dignity in their personal relationships. Based on interviews that were conducted with residents and staff, LPA could not prove or disprove the allegation. Furthermore, LPA was not made aware of any concerns during interviewing additional residents in care. During a tour of the facility conducted on July 6, 2023, LPA observed residents performing activities with one another. (Report continued on LIC 9099C) UnsubstantiatedRead the full finding— CDSS inspection report, July 6, 2023 · control 21-AS-20230614163014

Licensing Program Analyst Cuadra arrived unannounced to conduct a complaint investigation and deliver findings regarding the above allegations and met with Executive Director Morgan Holien. It was alleged that the facility is not following specialized diets. Per Reporting Party, the facility indicates residents with low sodium diet to bring their own food to the chef for them to cook it. Based on records review, the facility provided weekly menus for the month of October 2022 including an option called “Anytime Dining” offering residents in care a variety of food options. LPA conducted interviews with Executive Director who provided continuous meeting notes starting on May 25, 2022 indicating that resident (R1), facility chef, Health Services Director, Long Term Ombudsman were present addressing food options available for R1 who has a low sodium special diet in their Physician’s report dated March 1, 2022. LPA learned based on information obtained from confidential interviews that R1 wRead the full finding— CDSS inspection report, January 20, 2023 · control 21-AS-20221012111855