Oakmont of Concord

Type of visit: Case Management - Other

On 08/14/2026 at 12:15PM, Licensing Program Analyst (LPA) Andrew Christy and conducted an unannounced case management visit as a follow-up to an incident report received from the facility on October 29, 2025. LPA met with Executive Director San Sor and explained the purpose of the visit. On July 10, 2026, the Department concluded an incident report investigation regarding a facility staff (S1) slapping resident (R1) across the face resulting in facial bruising. On July 10, 2026, the Licensee was cited for violating Health and Safety Code § 1569.269(a)(10) Enumerated rights; severability. At the time of the case management visit on July 10, 2026, an immediate civil penalty of $500 was issued and the Licensee was informed that an additional civil penalty might be assessed based on Health and Safety Code § 1569.49(f). The Department has concluded an analysis and has determined that a civil penalty is warranted for physical abuse. The Welfare and Institutions Code Section 15610.63 for physical abuse means any of the following: (b) Battery, as defined in Section 242 of the Penal Code. This is evidenced by the facility staff (S1) slapping resident (R1) across the face resulting in facial bruising. Police report # 25-11309 stated Officer Fred Brooks #0675 observed a deep red approximate 4-inch bruise on R1’s right cheek and some redness of R1’s right eye. Today, August 14, 2026, the Department will be issuing a civil penalty per Health and Safety Code § 1569.49(f) for a violation that the Department constitutes as physical abuse in the amount of $10,000. However, since an immediate civil penalty of $500 was previously issued on July 10, 2026, the amount of the civil penalty issued today will be $9,500. Exit interview conducted. A copy of the report issued. Appeal rights provided. San Sor and the signature on this report acknowledges receipt of the appeal rights, found on page two of LIC 421D.the state’s words, verbatim · CDSS document, Aug 14, 2026

Type of visit: Required - 1 Year

On at 8:30AM, Licensing Program Analyst (LPA) Andrew Christy arrived unannounced to conduct the 1-Year Annual Required inspection. LPA met with Executive Director, San Sor, and explained the purpose of the visit. The facility currently houses 85 residents with a max capacity of 121 residents. LPA toured facility including but not limited to bedrooms, bathrooms, kitchen, common area, and backyard. All outdoor and indoor passageways are kept free of obstruction. A comfortable indoor temperature is maintained at 69.0 degrees Fahrenheit. The hot water temperature in the residents’ shared bathroom was measured at 112.7 degrees Fahrenheit. LPA observed lighting in all rooms are adequate for the comfort and safety of the residents. Residents’ bathrooms are equipped with grab bars and non-skid mats. There is a minimum of one week supply of non-perishable and 2 day of perishable foods. Centrally stored medication and sharps were locked and inaccessible to residents. Smoke detectors and carbon monoxide detectors were in operating condition during visit. Fire extinguisher was last serviced on 02/03/2026. At 10:30AM, LPA reviewed five (5) resident files and five (5) staff files, all found to be complete. The emergency disaster plan was last reviewed 07/26/2026. Quarterly emergency drills were last conducted 07/18/2026. A review of resident medications and the Medication Administration Record (MAR) found no outstanding errors. No deficiencies cited during visit. Exit interview conducted and a copy of this report was provided to the administrator.the state’s words, verbatim · CDSS document, Aug 14, 2026

Type of visit: Case Management - Deficiencies

On 07/10/2026 at 8:30AM, Licensing Program Analyst (LPA) Andrew Christy arrived unannounced to conduct a case management visit for deficiencies. LPA is following up on the case management visit on 10/31/2025 regarding an assault of a resident by a staff member. LPA met with Executive Director San Sor and explained and the purpose of the visit. After discussion with Regional Manager Isaac Taggart, it was concluded that facility did not ensure the safety of R1 under their care, and as a result received injuries from caregiver S1. Deficiencies are cited per Title 22 California Code of Regulations and listed on LIC809D. Failure to submit proof of corrections (POC) by plan of correction due date and/or any repeat deficiencies within a 12-month period may result in civil penalties. Exit interview conducted. A copy of this report, along with Appeal Rights, was provided to the Executive Director.the state’s words, verbatim · CDSS document, Jul 10, 2026

From the deficiency page — Deficiency type: Type A · Section cited: HSC 1569.269(a)(10) · Plan of correction due date: Jul 11, 2026

1569.269(a)(10) (a) Residents of residential care facilities for the elderly shall have all of the following rights: (10) To be free from neglect, financial exploitation, involuntary seclusion, punishment, humiliation, intimidation, and verbal, mental, physical, or sexual abuse. This requirement is not met as evidenced by: Based on observation, interviews, and record review, the licensee did not comply with the section cited above as a staff member hit a resident in the face and caused a bruise, which poses an immediate health, safety, or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Jul 10, 2026

Plan of correction: The staff member was immediately suspended and, after an internal investigation, terminated. In addition, on or before plan of correction due date, Licensee will conduct an inservice regarding personal rights of residents in care and abuse reporting. An immediate civil penalty of $500.00 is being assessed. Civil penalty determination related to serious bodily injury is pending.

Type of visit: Case Management - Health Checks

On 07/01/2026 at 10:30AM, Licensing Program Analyst (LPA) Andrew Christy arrived unannounced to conduct the 1-Year Annual Required inspection. LPA met with Executive Director, San Sor, and explained the purpose of the visit. The facility currently houses 93 residents with a max capacity of 121 residents. LPA toured facility including but not limited to bedrooms, bathrooms, kitchen, common area, and backyard. All outdoor and indoor passageways are kept free of obstruction. No bodies of water were observed. A comfortable indoor temperature is maintained at 69.0 degrees Fahrenheit. The hot water temperature in the residents’ bathroom was measured at 107.4 degrees Fahrenheit. LPA observed lighting in all rooms are adequate for the comfort and safety of the residents. Residents’ bathrooms are equipped with grab bars and non-skid mats. There is a minimum of one week supply of non-perishable and 2 day of perishable foods. Centrally stored medication and sharps were locked and inaccessible to residents. Smoke detectors and carbon monoxide detectors were in operating condition during visit. Fire extinguisher was last serviced on 02/03/2026. No deficiencies cited during visit. Exit interview conducted and a copy of this report was provided to the administrator.the state’s words, verbatim · CDSS document, Jul 1, 2026

Allegation investigated: Staff are mismanaging resident's medications. Staff are not reporting incidents to proper agencies.

On 3/20/2026, Licensing Program Analyst (LPA) A. Gomez arrived unannounced to continue the complaint investigation and deliver findings. LPA met with Executive Director, San Sor and explained the purpose of the visit. During the course of the investigation LPA reviewed records including but not limited to charting notes, unusual incident reports (UIR's),physicians reports, and correspondences. Report continues on LIC9099-C Substantiated On the allegation "Staff are not reporting incidents to proper agencies." LPA reviewed charting notes and available unusual incident reports for R1. Based on a review of charting notes LPA identified over 35 incidents between March 2025 and November 2025 that required submitting an unusual incident report and/or SOC341 report of suspected abuse to the required parties and agencies. LPA observed that the facility submitted 1 unusual incident reports and 5 SOC341 report of suspected abuse during this time period. LPA observed that all required incidents where not reported as required by Title 22 therefore the allegation "Staff are not reporting incidents to proper agencies." is Substantiated. On the allegation "Staff are mismanaging resident's medications." LPA reviewed R1's MAR, charting notes, and correspondences with R1's physician and responsible party. LPA identified 9 occasions where R1 was administered their as needed PRN for agitation. R1 was a memory care resident and was unable to determine their need for the PRN and unable to communicate their symptoms clearly. LPA observed that there was not a record of the Facility staff contacting the resident's physician prior to each dose, describing the resident's symptoms, and receiving direction to assist the resident in self-administration of that dose of medication as required by Title 22 therefore the allegation "Staff are mismanaging resident's medications." is Substantiated. Based on LPAs observations and interviews which were conducted and record reviews, the preponderance of evidence standard has been met, therefore the above allegations are found to be SUBSTANTIATED. California Code of Regulations (Title 22, Division 6, Chapter 8), are being cited on the attached LIC 9099D. Exit interview conducted with Executive Director, San Sor. Appeal rights and copy of this report provided.the state’s words, verbatim · CDSS document, Mar 20, 2026 · control 15-AS-20250710094801

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87211(a)(1)(D) · Plan of correction due date: Mar 27, 2026

(a) Each licensee shall furnish...but not limited to, the following:(1)A written report shall be submitted... within seven days of the occurrence of any of the events specified in (A) through (D) below...(D) Any incident which threatens the welfare, ...of any resident. This requirement was not met as evidence by: Based on record review of R1's charting notes and available UIR's the facility did not report all incidents as required. LPA identified over 35 reportable incidents and observed that the facility only had record of reporting 6 incidents which posed a potential safety and personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Mar 20, 2026

Plan of correction: By POC facility agrees to conduct a refresher course on reporting requirements for all staff and notify CCLD.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87465(d) · Plan of correction due date: Mar 27, 2026

(d) If the resident is unable to determine his/her own need for a prescription or nonprescription PRN medication, and is unable to communicate his/her symptoms clearly, facility staff designated by the licensee, shall be permitted to assist the resident with self-administration provided all of the following requirements are met: Based on record review of R1's charting notes and correspondenses with their physician LPA identified at least 9 times R1 was administered their PRN but was unable to identify any instances where the physician was contacted prior and all of the requirements were met for administering a PRN to a resident who can not determine their need or communicate their symptoms which posed a potential health and personal rights risk to residents in carethe state’s words, verbatim · CDSS document, Mar 20, 2026

Plan of correction: By POC facility agrees to conduct a refresher course on incidental medical and dental care for all staff administering medications and notify CCLD.

Allegation investigated: Facility is in disrepair Facility is not adequetly staffed

On 3/20/2026, Licensing Program Analyst (LPA) A. Gomez arrived unannounced to continue the complaint investigation and deliver findings. LPA met with Executive Director, San Sor and explained the purpose of the visit. During the course of the investigation LPA reviewed records including but not limited to care notes, care plans, staff schedules, toured facility, tested call buttons, and conducted interviews. Report continues on LIC9099-C Substantiated On the allegation "Facility is in disrepair" on 8/27/2025 LPA inspected a random selection of residents rooms. LPA observed that residents personal pendents are having issues notifying staff when pressed and ED as well as the HSD confirmed that there is a dead zone for rooms 201-204 as well as rooms 243 and 241 which they were actively trying to get resolved. At the time of the visit the pendents were not working and were in disrepair therefore the allegation Facility is in disrepair is substantiated. On the allegation "Facility is not adequately staffed" LPA conducted interviews on 3/20/2024 with residents as well as reviewed staffing available for the month of August 2025. LPA interviewed R1, R2, and R3. All residents stated that they feel that there is not enough staffing and that they have had trouble with getting assistance in a timely manner as a result. R1 stated that the facility has had issues with staffing and high turnover. R2 stated that they notice staffing is short especially on the weekends and that they have been told that they will have to wait longer due to the shortage. R2 also stated that there are sometimes only 2 staff for all of assisted living (AL) R3 stated that when they press their pendant to get assistance it can take a really long time due to the shortage of staff. LPA observed that on 8/24/2025 there was only 1 caregiver and 1 medtech available in AL from 6am- 2pm. Originally 2 caregivers were scheduled however 1 called out. On 8/24/2025 the census was 56 in AL and 31 in memory care (MC). Memory care typically has at least 5 caregivers on shift. Therefore the allegation "Facility is not adequately staffed" is substantiated. Based on LPAs observations and interviews which were conducted and record reviews, the preponderance of evidence standard has been met, therefore the above allegations are found to be SUBSTANTIATED. California Code of Regulations (Title 22, Division 6, Chapter 8), are being cited on the attached LIC 9099D. Exit interview conducted with Executive Director, San Sor. Appeal rights and copy of this report provided. On the allegation "Facility left residents unattended" LPA reviewed schedules and was unable to identify a time when there were no staff available to residents. Through interviews the LPA did identify that there have been times where staff were insufficient however LPA did not observe that zero staff were present therefore the allegation "Facility left residents unattended" is unsubstantiated. On the allegation "Facility did not ensure residents receive meals as scheduled" LPA conducted interviews with residents and reviewed staffing schedules and was unable to identify a time when the Facility did not ensure residents received meals as scheduled. All residents interviewed state that they have always gotten their meals within their time frames or went down to dinning, therefore the allegation is unsubstantiated. On the allegation "Residents needs and services are not being met" LPA conducted interviews with residents and reviewed care plans. LPA also reviewed previous complaints and identified that due to pendent malfunctions residents were left soiled for prolonged periods of times however LPA will not recite because it was already addressed on complaint 15-AS-20250731111939. LPA did find during their interviews that residents had to wait longer for their needs and services to be met however they did still receive the care therefore the allegation Residents needs and services are not being met is unsubstantiated. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED. A copy of this report provided.the state’s words, verbatim · CDSS document, Mar 20, 2026 · control 15-AS-20250825145826

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87303(a) · Plan of correction due date: Mar 27, 2026

(a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. This requirment was not met as evidence by: Based on observation and interviews on 8/27/2025 the facility had a number of call buttons in disrepair which posed a potential safety and personal rights risk to residents in carethe state’s words, verbatim · CDSS document, Mar 20, 2026

Plan of correction: By POC facility agrees to test all call buttons and ensure they are operational and notify CCLD

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87411(a) · Plan of correction due date: Mar 27, 2026

(a) Facility personnel shall at all times be sufficient in numbers... The licensing agency may require any facility to provide additional staff whenever it determines through documentation that the needs of the particular residents, the extent of services provided, or the physical arrangements of the facility require such additional staff for the provision of adequate services. This requirment was not met as evidence by: Based on record review and interviews the facility does not have suffient staffing for AL. Residents reported having long wait times and being told that they were short staffed by other staff members which poses a potential personal rights risk to residents in carethe state’s words, verbatim · CDSS document, Mar 20, 2026

Plan of correction: By POC facility agrees to review staffing needs and all AL careplans and identify how many additional staff need to be hired and notify CCLD.

Allegation investigated: Staff left resident soiled for an extended period of time. Staff did not answer resident's call button in a timely manner.

On 01/28/2026 at 11:00am, Licensing Program Analyst (LPA), Carol Fowler arrived unannounced to deliver complaint findings for the above allegations. . LPA met with Kim Sor, Executive Director and explained the reason for the visit. During the course of the inestigation, LPA interviewed five (5) staff and four (4) residents, LPA received and reviewed the following documents, resident roster with contact information, Personnel record (LIC500), LIC602 for R1, R1's assessment, and staff schedule for the period of 07/20/2025-08/02/2025. CONTINUE ON LIC 9099C Substantiated CONTINUE FROM LIC 9099 Allegation: Staff left resident soiled for an extended period of time. Investigation Finding: substantiated. R1 reported using the facility provided pendant to request assistance, R1 stated that R1 calls the front desk during daytime hours. R1 stated that R1 was left soiled for more than three hours. Staff member S3 reported responding to R1 but indicated that staff member S2 who was on duty did not respond to assist. During the investigation, S2 confirmed being on duty but acknowledged not responding to R1. Interviews with S2 revealed that two caregivers and one medication technician were assigned during the NOC shift; however, S2 stated that S2 was not assigned to R1 and was working on the opposite side of the building. S4 reported that staff are required to conduct routine rounds and change residents every two hours or as needed. Based on the evidence obtained this allegation is SUBSTANTIATED. Allegation: Staff did not answer resident's call button in a timely manner. Investigation Finding: substantiated. R1 reported that staff did not respond to the call pendant in a timely manner, resulting in the resident remaining soiled for several hours. R3 reported that call pendants were not functioning and stated they had been without a pendant for five days. R3 also reported that the facility is occasionally short staffed, particularly during the NOC shift, resulting in prolonged wait times for assistance. R4 reported that only three staff member are assigned during the NOC shift and that if R4 falls three staff members are required to assist R4 to get up. An interview with staff member S4 confirmed ongoing issues with the pendant system. S4 also reported that staff complete routine rounds to check residents for assistance needs. Based on the evidence obtained this allegation is SUBSTANTIATED. Deficiencies are cited per Title 22 California Code of Regulations and listed on LIC9099D. Failure to submit proof of correction (POC) by plan of correction due date and/or any repeat deficiencies within a 12-month period may result in civil penalties. Exit interview conducted. Appeal Rights and a copy of this report provided.the state’s words, verbatim · CDSS document, Jan 28, 2026 · control 15-AS-20250731111939

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87625(b)(2)(3) · Plan of correction due date: Feb 5, 2026

(b) In addition to Section 87611, General Requirements for Allowable Health Conditions, the ... (2) Ensuring that incontinent residents are checked ...are known to be incontinent, including during the night. (3) Ensuring that incontinent residents are kept clean and dry and ... Based on interviews, the ED did not comply with the regulation cited above by not providing care to residents in a timely manner which poses a potential health and safety risk to persons in care.the state’s words, verbatim · CDSS document, Jan 28, 2026

Plan of correction: Executive Director shall ensure staff are trained to meet the requirements under Sec. 87625 Managed Incontinence. Copies of completed training certificates, attendance sheet, and training agenda shall be received by the CCLD by the POC date.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87303(i)(1)(A)(B)(C) · Plan of correction due date: Feb 5, 2026

87303 Maintenance and Operation (i) Facilities shall have signal systems which ...criteria: (1) All facilities licensed for 16 or more and all residential facilities having separate floors or ... have a signal system which shall...(A) Operate...(B) Transmit...(C) Identify...unit -This requirement is not met as evidenced by: Based on interviews, the Executive Director did not comply with the regulation cited above by not ensuring that the call pendants were working properly at all times and not providing care to residents’ in a timely manner which poses a potential health and safety risk to persons in care.the state’s words, verbatim · CDSS document, Jan 28, 2026

Plan of correction: ED agreed to continue to monitor the system for the call pendants systems, alert all parties of malfunctions, review regulation, provide in-service training to all staff, and submit a copy of training with staff signatures to CCLD by POC.

Type of visit: Case Management - Incident

On 10/31/2025 at 1:30PM, Licensing Program Analysts (LPAs) Andrew Christy and Grace Luk arrived unannounced to conduct a Case Management visit regarding an Unusual Incident Report (LIC624) received on 10/29/2025. Incident involved a night shift staff member slapping a resident during care around 5:30AM. LPAs met with Executive Director San Sor and explained the purpose of the visit. Facility is currently at 95 residents with a max capacity of 121 residents. During the visit, LPAs collected the following documents: resident roster, employee roster, R1's Medical Assessment (LIC602), R1's Appraisal Needs And Services, R1's medication list, and S1's file. LPAs spoke to Executive Director to discuss what happened when the incident occurred and what steps have been taken to ensure that it does not happen again. Executive Director stated that they were informed of the incident that morning around 6:30AM. Executive Director was informed by S2, also a night shift employee that S1 reported bruising on R1's face, but the story of what happened during care has changed multiple times. R1 and R2 instead report that S1 was frustrated with them, and ended up slapping R1. A police report (#25-11309 with Officer F. Brooks) was filed after the incident, and S1 was called back in to explain their side of the story. Shortly after, due to the nature of the allegations and inconsistency of S1's story, S1 was put on leave until further notice. In regards for steps that have been taken ensure there is no future occurrence, Executive Director stated that there would be a new round of Mandated Reporter training. LPAs may return at a later time. No citations issued during visit. Exit interview conducted and a copy of this report was made available to the Executive Directorthe state’s words, verbatim · CDSS document, Oct 31, 2025

Type of visit: Required - 1 Year

On 08/08/2025 at 9:15AM, Licensing Program Analysts (LPAs) Andrew Christy and Yasamin Brown arrived unannounced to conduct the Required 1 Year Annual inspection. LPAs met Executive Director Kim Sor and explained the purpose of the visit. The facility currently houses 95 residents with a capacity of 121 residents.. LPAs toured the facility with executive director including, but not limited to, 5 residents’ apartments, activity rooms, kitchen, common areas, and courtyard. LPAs observed that lighting in all rooms are adequate for the comfort and safety of the residents. Hallway temperature was maintained at 75.0 degrees Fahrenheit. The hot water temperature in a sample of residents' bathrooms were measured at 109.8, 112.8, & 107.0 degrees Fahrenheit. Residents’ bathrooms are equipped with grab bars and non-skid mats. There is a minimum of 7 day supply of nonperishable and 2 day of perishable foods. Centrally stored medications and sharps are locked and inaccessible to residents. First Aid kit was found to be complete. Fire extinguishers were last serviced on 07/04/2025. Emergency Disaster Plan last updated 07/29/2025. Fire drills were last conducted 05/27/2025. LPAs reviewed 5 staff files, all found to be complete and up to date. LPAs also reviewed 5 resident files, all found to be complete and up to date. MARs and medications for 5 residents were also reviewed and no errors were found. No deficiencies found during visit. Exit interview conducted and a copy of this report was made available to the executive director.the state’s words, verbatim · CDSS document, Aug 8, 2025

Allegation investigated: Residents sustain unexplained injuries while in care. Staff did not provide medical attention to resident in a timely manner. Staff mismanage resident's medication. Resident not administered medication as prescribed. Residents' medication records not complete. Residents' medical assessments outdated.

On this day, 7/02/25, at 2:35 pm, Licensing Program Analyst (LPA) Delmundo arrived unannounced to deliver the findings for the above allegations. LPA met with Executive Director (ED) San Sor, and informed the reason for visit. During the course of investigation, LPA obtained copies of resident roster. LPA reviewed residents records and obtained copies of including but not limited to Resident Information Forms, doctor’s orders of medications, Medication Administration Records (MARs) and staff notes/documentations, hospital After Visit Summary, facility communication to residents’ doctors. LPA conducted inspection on 11/19/21 and interviewed staff (S1, S2), previous Memory Care Director (FMCD) and residents (R1 and R2). .......continued on 9099C(page 2) Unsubstantiated Page 2 Allegation: Residents sustained unexplained injuries while in care. Allegation: Staff did not provide medical attention to resident in a timely manner. Reporting party (RP) stated residents sustain skin tear, bruising and no one will report to the doctor until later and no one will follow-up. FMCD stated there’s no resident specifically in Memory Care (MC) sustained unexplained injury and/or bruising. FMCD stated there’s a resident in MC who sustained bruising on 11/19/21 and was reported to her that same day. FMCD further stated that will enter it internally and when she entered it, it's automatic that the Health Services Director will see it and HSD will submit the report to Community Care Licensing. The 2 staff stated when residents have incidents, the facility nurse assess and staff call 9-1-1 when needed. One of these 2 staff stated that if a resident sustains unexplained injury and/or bruising, the caregiver reports to the med-tech who in turn reports to the primary care physician. The 2 residents interviewed stated when they need help, the staff assist. Therefore, the above allegations are unsubstantiated. Allegation: Staff mismanage resident's medication. Allegation: Resident not administered medication as prescribed. Allegation: Residents' medication records not complete. RP stated the med-room is a mess, residents run out of medication due to pharmacy is not on top of it and residents not administered medication. RP also stated that the Central Log for medications is a mess and no dates medications were started. .....continued 9099C (page 3) Page 3 One of 2 staff stated the residents medications are refilled 5 to 7 days before they run out. The facility has an in-house pharmacy but some residents/family members have their preferred pharmacy. This staff and the other staff both stated residents missed medications due to insurance issues and family members not delivering the medications timely. During inspection, LPA observed the med-room organized. LPA reviewed the MARs and checked with the med-tech the information entered in the computer which showed including but not limited to Alert Charting, medications that were discontinued and medications refusals. Although hard copies of LIC622 LPA obtained some not having dates medications started, however, the information were entered in the computer. Therefore, the 3 allegations are unsubstantiated. Allegation: Residents' medical assessment outdated. Previous staff worker stated assessments are not being done timely. LPA selected 4 residents and reviewed their records which showed LIC602A Medical Assessments were less than a year old. Assessments were up to date. Therefore, the allegation is unsubstantiated. A finding that a complaint is unsubstantiated means that although the allegations may have happened or valid, there is not a preponderance of evidence to prove that violations occurred. No deficiency cited. Exit interview conducted and copy of this report provided.the state’s words, verbatim · CDSS document, Jul 2, 2025 · control 15-AS-20211116122617

Allegation investigated: Staff did not follow communicable infection protocols

On 04/11/2025 at 1:30PM, Licensing Program Analysts (LPAs) J. Clancy-Czuleger arrived unannounced to conduct a complaint visit. LPA explained the purpose of the visit with Executive Director Kim Sor. On the allegation facility staff did not follow communicable infection protocols. Based on record review and interviews the facility did have one resident who received a diagnosis of noro virus but was in the hospital for the entirety infectious period. When the resident returned the facility did their enhanced cleaning protocol and kept a close eye on other residents and staff and there have been no other confirmed cases. Although the allegations may have happened or are valid, there are not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are UNSUBSTANTIATED. Exit interview conducted and a copy of this report provided. Unsubstantiatedthe state’s words, verbatim · CDSS document, Apr 11, 2025 · control 15-AS-20250408105523

Allegation investigated: Staff engaged in inappropriate behavior resulting in resident sustaining in injury.

On 03/19/25 around 9:00 AM, Licensing Program Analyst (LPA) L. Holmes arrived unannounced to deliver the finding for the above allegation. LPA met with Kim Sor, Executive Director (ED) and explained the purpose of the visit. During the investigation and visits, LPA L. Holmes and L. Alexander toured the facility, interviewed Staff (S1, S2, S4, S5), reviewed statements from S2, S3 and S6, and reviewed the following documents: Resident Roster and Personnel Record (LIC500) designating Memory Care (MC), R1's LIC602, R1’s ID/Emergency contact information, and R1’s LIC624. Executive Director (ED) provided the local police report number and internal investigation report. Continued on LIC9099... Unsubstantiated ...continued from LIC9099. Allegation: Staff engaged in inappropriate behavior resulting in resident sustaining in injury. On 01/14/25 R1, a resident of Memory Care, attempted to enter the dining room by trailing S3 which was where other staff members were preparing for the evening meals. Records and interviews from S1, S3, S4, S5 and S6 revealed that R1’s fall was not a result of S3’s inappropriate behavior. S1 stated that R1 was yelling, swearing, tugging at the dining room door, and lost his/her balance. S4 assisted with calming R1 as he/she did not want to be restrained by the paramedics for medical attention, and S5 stated, “Perhaps S3 was not aware of R1 behaviors. R1 was getting agitated, combative, and slapping our (S4, S5 and EMT’s) hands. As of late, R1 has been a fall risk and is on Hospice medication. R1 is always walking, touching things, and standing.” Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did occur, therefore, the allegation is UNSUBSTANTIATED. Exit interview conducted and a copy of this report provided to ED.the state’s words, verbatim · CDSS document, Mar 19, 2025 · control 15-AS-20250115085215

Type of visit: Case Management - Other

On 03/19/25 around 10:00 AM, Licensing Program Analyst (LPA) L. Holmes arrived unannounced to deliver the finding for complaint #15-AS-20250115085215 on 01/15/25. In addition, LPA conducted a case management and met with Kim Sor, Executive Director (ED) and explained the purpose of the visit. On 01/15/25, S4 conducted counseling with S3 that included Care Provider Job Description, Fall Management Protocol, and Residents Rights - Employee Version. Per the interviews conducted for the above complaint with S1, S2, S4 and S5, LPA recommends the above trainings, in addition to Diversity, Equity, and Inclusion (DEI) training for S2. No citations issued, exit interview conducted and a copy of this report provided to ED.the state’s words, verbatim · CDSS document, Mar 19, 2025

Type of visit: Case Management - Incident

On 1/16/25, Licensing Program Analyst (LPA) K. Nguyen arrived unannounced to conduct a case management visit due to receiving a LIC624 regarding an incident that occurred on 12/31/24 when a staff (S1) member working in the memory care unit yelling at resident's (R1). LPA met with Kim Sor, Executive Director and explained the purpose of the visit. LPA interviewed S2 regarding the incident that occurred on 12/31/24. S2 stated S1's employment with the facility suspended on 12/31/2024 and then formally terminated on 1/5/25. Facility staff conducted a full investigation into the incident. S2 is deemed ineligible for re-hire. S2 admitted that S1 did yelled at the R1 and witness from other staff. S1 is no longer at the facility. R1 was evaluated after the incident and appeared to not have been adversely affected by the incident. S2 also stated that S1 was immediately suspended at the time of the incident and later terminated. Facility conducted a training on Elder Abuse Reporting on 12/25/24 and on 12/30/24 conducted a training on Residents Right Managing Aggressive Behavior as a reminder for staff to treat the residents with respect. No deficiencies cited during visit. Exit interview conducted and a copy of this report provided.the state’s words, verbatim · CDSS document, Jan 16, 2025

Type of visit: Case Management - Incident

On 1/08/25, Licensing Program Analyst (LPA) Greg Clark arrived unannounced to conduct a case management visit due to receiving a LIC624 regarding an incident that occurred on 12/25/24 when a staff (S1) member working in the memory care unit placed tape on a resident's (R1) mouth to stop her from talking. LPA met with Kim Sor, Executive Director and explained the purpose of the visit. LPA reviewed S1's personnel file. S1's employment with the facility suspended on 12/25/24 and then formally terminated on 12/31/24. Facility staff conducted a full investigation into the incident. S1 is deemed ineligible for re-hire. S1 admitted that she did place tape on the residents mouth to prevent her from talking. S1 expressed remorse for her actions. LPA interviewed S2 who stated that R1 was evaluated after the incident and appeared to not have been adversely affected by the incident. S2 also stated that S1 was immediately suspended at the time of the incident and later terminated. LPA toured the memory care unit with S2 and observed that residents were well dressed, clean and appeared well cared for. Staff were observed to be engaging with the residents, including R1, in a variety of activities. Facility conducted a training on Resident Rights on 12/25/24 and 12/30/24 as a reminder for staff to treat the residents with respect. No deficiencies cited during visit. Exit interview conducted and a copy of this report provided.the state’s words, verbatim · CDSS document, Jan 8, 2025

Allegation investigated: Staff did not ensure that resident had required oxygen administration Staff mismanaged resident's medication Staff did not ensure that medication was inacessible to others

On 12/12/24 at 11AM, Licensing Program Analyst (LPA) D Panlilio conducted a subsequent complaint visit, met with executive director (ED), gathered information and delivered investigation findings to ED. LPA explained the purpose of the visit with ED. On 12/06/24 at 3PM, LPA interviewed staff (ED, S1, S2) and obtained the following documents: Resident roster with contact information, Personnel record (LIC500), R1's admission agreement, Hospice care plan, Doctors’ orders, Centrally stored medications & medication administration records (MARs), visitors logs (10/28 to 10/31). Continued on next page, LIC 9099-C Substantiated Allegation: Staff did not ensure that resident had required oxygen administration Investigation Finding: Substantiated On 12/10/24 at 3:30PM, staff (S1, S2) confirmed with LPA that memory care hospice resident’s (R1) oxygen machine was turned off by S2 on 10/29/24 around 6:20PM because the machine emitted intermittent screeching sounds which agitated R1. S2 also stated that he/she removed R1’s oxygen mask and then left R1’s room that day. S1 stated that she was getting ready to go home around 6:30PM when she asked S2 how R1 was doing and S2 told her that he/she turned off R1’s oxygen machine and removed her oxygen mask. S2 stated she told S2 to call the hospice care team regarding the incident and immediately went to R1, turned the oxygen machine on and placed her oxygen mask on. Based on records review, interviews conducted, and observations made, the department has investigated the above allegation that staff did not ensure that resident had required oxygen administration. The preponderance of evidence standard has been met, therefore the above allegation was found to be substantiated. Allegation: Staff mismanaged resident’s medication Investigation Finding: Substantiated On 12/10/24 at 4PM, staff (S1, S2) confirmed with LPA that hospice resident’s (R1) morphine medication was administered 2 hours late on 10/29/24. S2 stated he/she gave the morphine medication to S1 around 7PM instead of 5PM because he/she was waiting for R1’s medication dosage change orders which did not arrive on time. Review of R1’s medication administration records dated 10/29/24 showed R1’s morphine medication was to be administered every 4 hours as prescribed by the hospice care team for R1’s comfort care. Based on records review, interviews conducted, and observations made, the department has investigated the above allegation that staff mismanaged resident’s medication. The preponderance of evidence standard has been met, therefore the above allegation was found to be substantiated. Continued on next page, LIC 9099-C pg1 Allegation: Staff did not ensure that medication was inaccessible to others Investigation Finding: Substantiated On 12/10/24 at 4PM, staff (S1) confirmed with LPA that on 10/29/24 around 6:40PM, hospice resident’s (R1) morphine medication was left unattended on hospice resident’s (R1) side table in the presence of R1’s family members. S1 stated that she left the unopened morphine medication in R1’s room temporarily so she can take an important phone call from R1’s hospice care team for advice regarding the temporary removal of R1’s oxygen mask and oxygen machine turnoff. Based on records review, interviews conducted, and observations made, the department has investigated the above allegation that staff did not ensure that medication was inaccessible to others. The preponderance of evidence standard has been met, therefore the above allegation was found to be substantiated. Deficiencies are cited per Title 22 California Code of Regulations and listed on LIC9099D. Failure to submit proof of correction (POC) by plan of correction due date and/or any repeat deficiencies within a 12-month period may result in civil penalties. Exit interview conducted. Appeal Rights and a copy of this report provided.the state’s words, verbatim · CDSS document, Dec 12, 2024 · control 15-AS-20241206113512

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87633(d) · Plan of correction due date: Dec 30, 2024

The licensee shall ensure that the hospice care plan is current, accurately matches the services actually being provided, and that the client’s care needs are being met at all times. This requirement was not met as evidenced by staff failing to ensure that hospice resident had required oxygen administration as prescribed by the hospice care team which posed a potential health & safety risk to resident in care.the state’s words, verbatim · CDSS document, Dec 12, 2024

Plan of correction: By POC due date, administrator agreed to submit to CCL completed in-service staff retraining certifications on the proper implementation of hospice care plans specific to the current and ongoing needs of the hospice resident in compliance with Title 22 Section 87633 regulations.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87633(b)(2) · Plan of correction due date: Dec 30, 2024

A description of the services to be provided in the facility by the hospice agency including but not limited to the type and frequency of services to be provided. This requirement was not met as evidenced by staff failing to provide timely medication administration for comfort care which posed a potential health & safety risk to the hospice resident in care.the state’s words, verbatim · CDSS document, Dec 12, 2024

Plan of correction: By POC due date, administrator agreed to submit to CCL completed in-service staff retraining certifications on hospice care plan implementation in compliance with Title 22 Section 87633 regulations.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87633(k) · Plan of correction due date: Dec 30, 2024

The licensee shall maintain a record of dosages of medications that are centrally stored for each resident receiving hospice services in the facility… This requirement was not met as evidenced by staff failing to safely store a controlled substance which posed a potential health & safety risk to resident in care.the state’s words, verbatim · CDSS document, Dec 12, 2024

Plan of correction: By POC due date, administrator agreed to submit to CCL completed in-service staff retraining certifications on proper storage of controlled substances prior to being administered to the resident in compliance with Title 22 Section 87459 regulations.

Allegation investigated: Licensee does not ensure that facility call pendant system is functioning at all times for residents in care. Staff do not respond to residents' requests for assistance in a timely manner.

On 11/15/24 around 05:45 PM, Licensing Program Analyst (LPA) L. Holmes amended the report to update the allegations from 11/04/24 around 03:30 PM when LPA arrived unannounced to deliver the complaint findings for the above allegations. LPA met with San Sor, Executive Director (ED) and explained the purpose of the visit; ED approved Kashvi Patel, Concierge to sign the report. During the course of the investigation LPA interviewed ED, Staff and Residents. LPA requested emails and other forms of communication that were sent to residents and responsible parties regarding Assisted Living (AL) pendant system and Memory Care (MC) call button; the documentation to include any communications that show the request for repairs and when repairs were completed for any outages. LPA requested Resident Roster, Staff Roster, current LIC 500 and LIC 500 dated 06/2024, Resident Council's agenda/minutes for 05/2024 and 06/2024, In-Service trainings, and Resident Council President's contact information. Continued on LIC9099C... Substantiated ...continued from 9099 to amend and separate allegations. Allegations: SUBSTANTIATED Licensee does not ensure that facility call pendant system is functioning at all times for residents in care. Staff do not respond to residents' requests for assistance in a timely manner. Licensee does not ensure that facility call pendant system is functioning at all times for residents in care. Documentation for In-Service Staff training did not include all Care Staff and Management for Pendant Response Times. Proof of notification that ensured all Staff, Families and Responsible Party’s were aware of the pendants malfunctioning and the processes until corrected was not provided to CCLD during the investigation. Interviews with Staff (S2, S3, S4, S6) and Residents (R1, R2, R3, R11) confirmed that the pendants weren’t working properly or consistently from June 2024 to October 2024. Staff do not respond to residents' requests for assistance in a timely manner. R1 stated that he/she had wait over and hour for a caregiver to come to the apartment. R3 stated that he/she has waited up to 30 minutes for Staff to respond. S2, S3, and S6 stated that if they needed a 2 person assist, for example if a Resident was in a wheelchair, the Care Staff would have to wait for a response to get assistance; the next Residents’ response time would be delayed as a result of the pendant not working properly. Deficiencies cited from Title 22 California Code of Regulations and listed on LIC9099D. Failure to submit proof of correction by plan of correction due date, and any repeat violations within a 12-month period may result in civil penalties. Exit interview conducted, appeal rights and a copy of this report provided to Kashvi Patel, Concierge.the state’s words, verbatim · CDSS document, Nov 15, 2024 · control 15-AS-20240705101641

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87303(i)(1)(A)(B)(C) · Plan of correction due date: Nov 22, 2024

87303 Maintenance and Operation (i) Facilities shall have signal systems which shall meet the following criteria: (1) All facilities licensed for 16 or more and all residential facilities having separate floors or buildings shall have a signal system which shall...(A) Operate...(B) Transmit...(C) Identify...unit -This requirement is not met as evidenced by: Based on interviews, the Licensee did not comply with the regulation cited above by not ensuring that the call pendant was working properly at all times or alerting all Staff and Residences of the processes during the malfunction, and not providing care to residents’ in a timely manner which posed/poses a potential health and safety risk to persons in care.the state’s words, verbatim · CDSS document, Nov 15, 2024

Plan of correction: ED agreed to continue to monitor the system for the call pendants systems, alert all parties of malfunctions, review regulation, provide in-service training to all staff, and submit a copy of training with staff signatures to CCLD by POC.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87464(f)(1) · Plan of correction due date: Nov 22, 2024

87464 Basic Services (f) Basic services shall at a minimum include: (1) Care and supervision as defined in Section 87101(c)(3) and Health and Safety Code section 1569.2(c). -This requirement is not met as evidenced by: Based on interviews, the Licensee did not comply with the regulation cited above by not providing care to residents’ in a timely manner which posed/poses a potential health and safety risk to persons in care.the state’s words, verbatim · CDSS document, Nov 15, 2024

Plan of correction: ED agreed to assume responsibility or provide ongoing assistance with activities of daily living, medications, money management, or personal care. for the residents' physical health, mental health, safety and welfare by reviewiewing the regulation, provide in-service training to all staff, and submit a copy of training with staff signatures to CCLD by POC.

Allegation investigated: Staff retaliate against residents in care. Licensee does not ensure that a portion of resident council meetings are conducted without the presence of facility staff.

On 11/04/24 around 03:30 PM, Licensing Program Analyst (LPA) L. Holmes arrived unannounced to deliver the complaint findings for the above allegations. LPA met with San Sor, Executive Director (ED) and explained the purpose of the visit. During the course of the investigation LPA interviewed ED, Staff and Residents. LPA requested emails and other forms of communication that were sent to residents and responsible parties regarding Assisted Living (AL) pendant system and Memory Care (MC) call button; the documentation to include any communications that show the request for repairs and when repairs were completed for any outages. LPA requested Resident Roster, Staff Roster, current LIC 500 and LIC 500 dated 06/2024, Resident Council's agenda/minutes for 05/2024 and 06/2024, In-Service trainings, and Resident Council President's contact information. Continued on LIC9099C... Unsubstantiated ...Continued from LIC9099. Allegations: UNSUBSTANTIATED Staff retaliate against residents in care. Licensee does not ensure that a portion of resident council meetings are conducted without the presence of facility staff. Interviews with Staff (S2, S3, S4, S5, S6) and Residents (R1, R2, R3, R11) revealed that no one was aware of any forms of retaliation against residents. R3 stated that people expressed they were worried about retaliation, but R3 never experienced retaliation or heard any grievances about how the resident council meeting were conducted. The President of the Resident Council and ED confirmed the meetings would be conducted with Staff and Residents, and toward the end of the meetings the ED would adjourn for residents to consult with one another and return to conclude the meeting. Based on the information obtained the above allegations are UNSUBSTANTIATED.the state’s words, verbatim · CDSS document, Nov 4, 2024 · control 15-AS-20240705101641

Allegation investigated: Staff are not meeting the needs of residents in care.

On 11/15/24 around 05:45 PM, Licensing Program Analyst (LPA) L. Holmes amended the report to update the allegations from 11/04/24 around 03:30 PM when Licensing Program Analyst (LPA) L. Holmes arrived unannounced to deliver the complaint findings. LPA met with San Sor, Executive Director (ED) and explained the purpose of the visit; ED approved Kashvi Patel, Concierge to sign the report. During the course of the investigation LPA interviewed ED, Staff and Residents. LPA requested emails and other forms of communication that were sent to residents and responsible parties regarding Assisted Living (AL) pendant system and Memory Care (MC) call button; the documentation to include any communications that show the request for repairs and when repairs were completed for any outages. LPA requested Resident Roster, Staff Roster, current LIC 500 and LIC 500 dated 06/2024, Resident Council's agenda/minutes for 05/2024 and 06/2024, In-Service trainings, and Resident Council President's contact information. Continued on LIC9099C... Substantiated ...amended continuation from LIC9099. Allegations: SUBSTANTIATED Staff are not meeting the needs of residents in care. Staff are not meeting the needs of residents in care. ED stated the quality control and assurance checks have been performed monthly since August 2024 and that S9 (Health Services Director) was not employed during the of staff trainings; therefore, S9's name was not on the In-Service training Sign-in sheet, but will be updated on the trainings going forward. Due to these malfunctions and delayed response times, Staff were not meeting the needs of residents in care. Deficiency cited from Title 22 California Code of Regulations and listed on LIC9099D. Failure to submit proof of correction by plan of correction due date, and any repeat violations within a 12-month period may result in civil penalties. Exit interview conducted, appeal rights and a copy of this report provided to Kashvi Patel, Concierge.the state’s words, verbatim · CDSS document, Nov 4, 2024 · control 15-AS-20240705101641

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.1(a)(2) · Plan of correction due date: Nov 25, 2024

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 accommodations, furnishings and equipment.-This requirement is not met as evidenced by: Based on interviews, the Licensee did not comply with the regulation cited above by not ensuring that the call pendant was working properly at all times or alerting all Staff and Residences of the processes during the malfunction, and not providing care to residents’ in a timely manner which posed/poses a potential health and safety risk to persons in care.the state’s words, verbatim · CDSS document, Nov 4, 2024

Plan of correction: ED agreed to continue to monitor the system for the call pendants systems, alert all parties of malfunctions, review regulation, provide in-service training to all staff, and submit a copy of training with staff signatures to CCLD by POC.

Type of visit: Required - 1 Year

On 08/23/2024 at 9:29 AM, Licensing Program Analysts (LPAs) Ardalan Gharachorloo and David Doidge arrived unannounced to conduct 1-Year Annual Required inspection. LPAs met with Executive Director, San Sor and explained the purpose of the visit. LPAs toured the facility including but not limited to 3 residents’ apartments, bathrooms, multiple activity rooms, kitchen, common area and courtyard. LPAs observe lighting in all rooms are adequate for the comfort and safety of the residents. Hallway temperature was maintained at 73 degrees F. The hot water temperature in a residents’ shared bathroom was measured at 118.5 degrees Fahrenheit. Residents’ bathrooms are equipped with grab bars and non-skid mats. There is a minimum of one week supply of nonperishable and 2-day of perishable foods. Centrally stored medications, sharps and toxic are locked and inaccessible to residents in care. Smoke detectors and carbon monoxide detectors were in operating condition during visit. Fire extinguisher was last serviced on 02/07/2024. Emergency Disaster Plan was last posted on 01/01/2024. First aid kit was observed to be complete. Emergency disaster drill was last conducted on 06/27/2024. LPA reviewed 6 residents records and 6 staff records, and all were complete. LPA also reviewed a sample of resident’s medications. LPAs reviewed the following documents: LIC 610E Emergency Disaster Plan, the current Administrator’s Certificate and the current liability insurance, No deficiencies cited during visit. Exit interview conducted and a copy of this report provided.the state’s words, verbatim · CDSS document, Aug 23, 2024

The state marks this report as 3 pages; the online copy we transcribed has 1. You can request the full file from the county licensing office.

Allegation investigated: Staff are not enuring that residents' room phones are working properly

On 03/20/2024 at approximately 8:55 am Licensing Program Analyst (LPA) J. Clancy-Czuleger arrived unannounced to conduct the initial 10-day complaint visit. LPA explained the purpose of the visit with Executive Director Sal Sor. It was alleged that facility staff are not enuring that residents' room phones are working properly During the course of the investigation, LPA J. Clancy-Czuleger interviewed staff, residents, and residents responsible parties. It was confirmed that the facility does not control the residents individual phone lines and has not blocked any numbers for any residents. Staff stated that when a resident is having trouble with their phones they will assist them with trying to fix it. Therefore the above allegation is unfounded. A finding that the complaint is unfounded means that the allegation is false, could not have happened, and or is without a reasonable basis. No deficiency observed or cited during this visit. Exit interview conducted and a copy of this report provided. Unfoundedthe state’s words, verbatim · CDSS document, Mar 20, 2024 · control 15-AS-20240315140632