Oakmont of Fullerton

Allegation investigated: Facility did not seek medical attention in a timely manner.

Licensing Program Analyst (LPA) Joseph Alejandre made an unannounced visit to deliver the findings of the complaint investigation into the allegation listed above. LPA met Executive Director Maria Kauten and explained the reason for the visit. During the course of the investigation, Department staff inspected the facility, interviewed staff, witnesses and reviewed records, including resident roster, staff roster, staff schedule, Resident 1’s (R1) physician’s report dated June 2, 2022, R1’s preplacement appraisal dated May 31, 2022, elopement risk assessment dated May 31, 2022, R1’s functional capabilities assessment, Oakmont fall management protocol, R1’s resident care notes dated November 30, 2022 to January 15, 2023, R1’s resident and services agreement dated June 3, 2022 and R1’s St. Jude Medical Records dated January 11, 2023 through January 26, 2023. The investigation into the allegation, facility did not seek medical attention in a timely manner, revealed the following. Substantiated R1 moved into the facility on June 6, 2022. R1 was diagnosed with Hyperlipidemia, Dementia, Hyperparathyroidism, gout and had a pacemaker implant. R1 was reported to be ambulatory, could independently transfer to and from bed and did not require the use of a walker or wheelchair at the time of move in. R1 did not require assistance with most tasks. The fall risk evaluation showed R1 was a moderate fall risk and no written service plan for prevention of falls was indicated. On January 11, 2023, around 10:30 am R1 was being visited by their family. R1’s responsible party reported that R1 appeared to be in pain and observed a bruise on R1’s thigh. R1’s resident care notes dated January 8, 2023, list a bruise to R1’s thigh that may have been self-inflicted. Staff 2 (S2) reported that they noticed bruising on R1’s thigh around January 4 or January 5, 2023, and it was reported to R1’s responsible party. The name on the entry is illegible. Staff 1 (S1) reported R1 appeared fine all morning on January 11, 2023. R1’s responsible party reported that staff were unable to provide any history about the bruise on R1’s thigh. At 7:00 pm R1’s responsible party returned to the facility to visit R1. R1’s responsible party reported that staff was preparing R1 for bed and R1 was screaming. R1’s responsible party reported that that R1’s bruise was now swollen and R1 appeared to be in pain. R1’s responsible party reported that they asked Staff 1 (S1) to call 911 but S1 did not feel it was necessary to call 911 but they did so because of the request. R1 was transported to St. Jude Medical Center by ambulance. R1 was diagnosed with a distal interprosthetic fracture, a break in the femur between a hip replacement and a knee replacement. St. Jude medical records for R1 shows the attending physician noted, the fracture was of unclear chronicity (the onset cannot be precisely determined) and the injuries sustained appeared to have occurred two to three weeks earlier. R1’s responsible party reported that R1 had been unable to successfully transfer or bear weight since the beginning of January 2023. Facility staff could not corroborate this report. On January 13, 2023, R1 had surgery to repair their fracture. R1 was discharged from the hospital and moved to a skilled nursing facility for rehabilitation. R1 moved to another assisted facility after being discharged from the skilled nursing facility. R1 passed away on May 5, 2023, under hospice care. It is unknown how or when R1 sustained their fracture and the bruise on R1’s thigh was never addressed until January 11, 2023, when R1’s responsible party requested R1 be taken to the hospital. R1 was diagnosed with a distal interprosthetic fracture on January 11, 2023, and the medical records show the fracture was 2 to 3 weeks old. During the course of the investigation, the Department obtained sufficient evidence to substantiate the allegation, facility did not seek medical attention in a timely manner. See LIC9099D for cited deficiencies per Title 22 Division 6 of the California Code of Regulations. Immediate civil penalties are being assessed. See LIC421IM. A Civil Penalty is pending determination by the Community Care Licensing Division (CCLD) per Health & Safety Code section 1569.49(f). An exit interview was conducted, and a copy of this report and appeal rights were discussed with and provided to facility representative. R1 did not require assistance with most tasks. The fall risk evaluation showed R1 was a moderate fall risk and no written service plan for prevention of falls was indicated. R1 suffered two reported falls while residing at the facility. The first fall occurred on September 4, 2022. R1 was walking in the hallway with their Responsible Party when they fell on their right side and they hit their face on the ground. R1 sustained a skin tear to the right eyebrow. R1 was transported to urgent care by their Responsible Party. R1 received treatment, glue strips were applied to R1’s eyebrow by Urgent Care. No other injuries were reported. On November 29, 2022, R1 had an unwitnessed fall. R1 was found in a sitting position in the dining room by their chair, no visible injuries were reported. Staff were instructed to monitor R1 for any changes. No further concerns were reported. The staff reported all falls they had knowledge of. R1 continued to ambulate with the assistance of a walker and sometimes utilized a wheelchair up until January 11, 2023, when R1 was transported to the hospital. No additional falls were reported that may have caused the bruising and fracture. It is unclear when, where or how R1 sustained their injuries which prompted R1’s hospitalization on January 11, 2023. There was nothing noted in R1’s service plan or appraisal that recommended standby assistance for walking or getting around the facility. Based on the interviews conducted and documents reviewed, the Department is unable to ascertain if the allegation occurred as reported. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove or refute the alleged violation occurred; therefore, the allegation is deemed unsubstantiated. The investigation into the allegation, facility did not report an incident to resident’s responsible party revealed the following. R1 resided at the facility from June 6, 2022, until January 11, 2023. R1 suffered 2 documented falls during their stay at the facility. The first fall was on September 4, 2022, and the second fall on November 29, 2022. R1’s last day at the facility was on January 11, 2022, when R1 was transported to the hospital and admitted due to their distal interprosthetic fracture, a break in the femur between a hip replacement and a knee replacement. According to hospital records the injury occurred 2 to 3 weeks prior to January 11, 2023. R1’s responsible party was present on January 11 and was notified R1 would be transported to the hospital. R1’s responsible party reported the facility reported on R1’s status regularly and should have known if R1 had an additional unwitnessed fall that caused R1’s fracture. Staff 1 (S1) reported that the bruise on R1’s thigh was reported to R1’s responsible party on January 4 or 5, 2023, R1’s responsible party did not verify this report. R1’s bruise (on the same leg as the fracture) was documented on facility records on January 8, 2023. R1’s responsible party reported they first found out about the bruise on January 11, 2023, the day R1 was transported to the hospital. It is unknown if R1 had additional unwitnessed falls. R1’s responsible party acknowledged the facility reported to them regularly regarding R1’s condition and known falls. The facility reported the falls they had knowledge of. There is no way to determine how R1 sustained their fracture. There are no records to show that R1 was found on the floor or displayed behaviors in January prior to January 11, 2023, that would lead the facility to suspect R1 had suffered an unwitnessed fall, except for the bruise on R1’s thigh. Facility staff reported R1’s responsible party was notified about the bruise. The facility cannot be expected to report an incident they have no knowledge of. Based on the interviews conducted and documents reviewed, the Department is unable to ascertain if the allegation occurred as reported. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove or refute the alleged violation occurred; therefore, the allegation is deemed unsubstantiated.the state’s words, verbatim · CDSS document, May 15, 2026 · control 22-AS-20230130171142

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(g) · Plan of correction due date: May 16, 2026

87465(g) The licensee shall immediately telephone 9-1-1 if an injury or other circumstance has resulted in an imminent threat to a resident’s health including, but not limited to, an apparent life-threatening medical crisis except as specified in Sections 87469(c)(2), (c)(3), or (c)(4). This requirement was not met as evidenced by R1 sustained a distal interprosthetic fracture 2 to 3 weeks prior to 911 being called on January 11, 2023, at the insistence of R1’s responsible party. This poses an immediate health, safety and personal rights risk to residents in care.the state’s words, verbatim · CDSS document, May 15, 2026

Plan of correction: Licensee to train all care staff on CCR 87465 and to submit proof of training to LPA.

Allegation investigated: Facility staff did not safeguard residents' cash resources

Licensing Program Analyst (LPA) Rose Ruppert made an unannounced visit to deliver findings for a complaint received in the Regional Office. LPA was greeted and granted entry by the Concierge at 2:30pm. LPA met with Executive Director (ED) Maria Kauten and explained the purpose of the visit. LPA reviewed the following documents for Resident #1 (R1): The Lease Agreement, Durable Power of Attorney documents, Resident Information Sheet and Form, Physician's Report dated 2/25/2026, Preplacement Appraisal, and R1's most recent Care Plan dated 2/11/2025. LPA also obtained signed Inventory Sheet by R1 who stated they did not wish to inventory personal belongings. It was alleged that: Facility staff did not safeguard residents' cash resources. LPA reviewed R1's documentation. R1 moved in on February 28, 2023 and R1 did not wish to inventory personal items. R1 does not have neurocognitive impairment and preferred to stay in the apartment. R1 was able to ambulate (Continued on LIC 9099-C) Unsubstantiated (Continued from LIC 9099) independently but did receive assistance with Activities of Daily Living (ADL) per care plan. LPA interviewed four of four staff members who routinely engaged with Resident #1 (R1) and/ or provided direct care to R1. Four of four staff were unaware of the allegation and stated R1 had never shared that any personal items or cash were missing. Staff stated that residents in the community do not normally carry cash and they were unaware that any cash was in R1's possession or needed to be safeguarded. Resident #1 pays for services through their Power of Attorney (POA) monthly and POA did not mention any items or cash missing for R1, to facility. LPA attempted to interview residents who were close to R1. Two of the three residents were unavailable to be interviewed. One resident interviewed stated there were never discussions at the dinner table regarding missing items or financial abuse. The resident stated they have not experienced anything missing in their apartment and does not suspect financial abuse occurring in the community. LPA interviewed two of two witnesses. One witness was aware of the allegation but could not confirm, nor deny the allegation. The second witness had no knowledge of the allegation and could not confirm, nor deny that Facility staff did not safeguard residents' cash resources. Based on LPA's file review and interviews, the allegation that Facility staff did not safeguard residents' cash resources is Unsubstantiated. The allegation may have happened or is valid, but there is not a preponderance of the evidence to prove that the alleged violation occurred. An exit interview was conducted with Executive Director (ED) Maria Kauten, and a copy of this report was provided to the facility.the state’s words, verbatim · CDSS document, May 15, 2026 · control 22-AS-20260430160439

Allegation investigated: Due to lack of supervision, resident fell and sustained injuries.

On May 14, 2026, at 12:15 PM, Licensing Program Analyst (LPA) Edward Kim conducted a subsequent complaint visit to deliver complaint investigation findings. LPA met with Administrator (ADMIN) Maria Kauten and explained the purpose of today’s visit. The investigation consisted of the following: LPA Kim conducted a tour of the facility. LPA Kim obtained and reviewed copies of the resident and staff rosters, and resident records which include the Physician’s Reports, Appraisal/Needs and Services Plans, and other pertinent records. LPA conducted interviews with one resident, three staff, and two witnesses. The investigation revealed the following: Continued on LIC9099C Unsubstantiated Allegation: Due to lack of supervision, resident fell and sustained injuries It is alleged resident was sent to the hospital due to a fall at the facility. It is alleged that the resident had multiple falls that led to bruising in multiple areas and will require a procedure. Based on record review, resident #1’s (R1) physician report dated March 9, 2026, diagnosed R1 with Vertigo, Hypertension, nonambulatory, and recurrent falls. R1’s Preplacement Appraisal Form dated February 15, 2026, stated R1 uses a walker and can transfer themselves on and off by themselves. It also states the R1 needs help moving around the facility because they get tired quickly. An Incident report dated March 19, 2026, stated R1 was found on the floor on March 18, 2026, at 9:50 PM. R1 hit their head and was transported to the hospital. Primary Care Physician and Power of Attorney were notified. The Facility charting notes for R1 stated on March 18, 2026, around 9:50 PM, R1 was found on the floor due to tripping and losing their balance. Staff observed R1 had an altered mental status and laceration on their forehead. R1 was transported to the hospital. Facility Charting Notes stated R1 returned to the facility on March 25, 2026, with a one-on-one caregiver present with them for 24 hours for three days. Based on interviews, one resident, three out of three staff, and two witnesses denied the allegation. R1 stated that on March 18, 2026, at night, they were walking without their walker from their closet to their bed, which led to them falling that night. The fall occurred and R1 crawled to their bed for their pendant and pressed the button. R1 recalls the fall led to their hip pain and laceration on their forehead. R1 had an unwitnessed fall on December 17, 2025, which resulted with head pain. In both instances, R1 stated that they should have been using their walker. They know they should have used their walker to move around before they fell but chose not to use it in their unit. R1 stated the facility did nothing wrong and R1 needed to be more responsible. LPA observed R1’s unit, they had several signs posted up to remind R1 to always use their walker. R1 stated those were made by their son because of the fall on March 18, 2026. Witness #1 (W1) and Witness #2 (W2) stated they do not suspect that the fall was due to negligence, lack of care, or lack of supervision. W1 stated that the facility does a good job in meeting R1’s activities of daily living. They stated the facility responded in a timely manner and provided the care and supervision based on Continued on LIC9099C R1’s needs. When the falls occurred on December and March, W1 stated they were informed in a timely manner. S1 and S2 stated that they are meeting and providing the care and supervision for R1’s daily needs. S3 stated on March 18, 2026, they responded to the pendant being pressed. S3 went to R1’s unit and found them on the floor with a laceration on their head. S3 called for assistance and 911 was called. Based on the information gathered, there is no sufficient evidence to confirm the above allegation. Based on observations, interviews, and records review, LPA did not find sufficient evidence to support the above allegation that due to lack of supervision, resident fell and sustained injuries. Although the allegation may have happened or are valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegations are Unsubstantiated. Exit interview was conducted and a copy of the report was provided to Administrator Maria Kauten.the state’s words, verbatim · CDSS document, May 14, 2026 · control 22-AS-20260320131240

Allegation investigated: Staff failed to respond in a timely manner. Facility instructed staff to withhold information from the Department

Licensing Program Analyst (LPA) Jerome Haley made an unannounced visit to investigate the complaint allegations listed above. LPA was greeted and granted entry by staff after introducing himself and stating the purpose of the visit. The complaint investigation consisted of interviews with facility staff, residents, a witness, document review, and observations. Regarding allegation: Staff failed to respond in a timely manner. During interviews 10 of 11 individuals failed to provide any corroborating evidence or information. According to residents, facility staff are responsive. According to Resident 2 (R2) staff are quick. Resident 3 (R3) said the same thing, staff respond quickly. S3 said one time their pendant was pressed by accident, and the staff were at my door fast! During an interview with Staff 6 (S6) LPA observed the staff’s pager going off. S6 got on their walkie talkie and asked for someone to check on a resident. The staff member on the other end of the radio responded immediately, and said the resident was eating. Continued on LIC9099C Unfounded Regarding allegation: Facility instructed staff to withhold information from the Department During interviews 6 of 6 staff members immediately denied the allegation. Multiple staff members stated they would report it to someone, if they were instructed to withhold information. LPA Haley then asked the staff members what they would do if someone asked them to do something like that and a few of the responses from staff were: I would report it to the Executive Director; I would report it to Licensing. One staff member said they would report it to the LPA. Based on the information gathered through interviews, document review and observation, the allegations are deemed unfounded, meaning the allegations are false, could not have happened and/or is without a reasonable basis. An exit interview was conducted, and a copy of this report was provided.the state’s words, verbatim · CDSS document, Feb 11, 2026 · control 22-AS-20260202151159

Allegation investigated: Staff spoke inappropriately to resident in care

On January 30, 2026, Licensing Program Analyst (LPA) Edward Kim conducted a subsequent complaint visit to deliver complaint investigation findings. LPA met with Executive Director (ED) Maria Kauten and explained the purpose of today’s visit. The investigation consisted of the following: LPA Kim conducted a tour at the facility. LPA Kim obtained and reviewed copies of the resident and staff rosters, resident records which include the Physician’s Reports, Appraisal/Needs and Services Plans, and other pertinent records for five staff. LPA Kim conducted interviews with seven residents, eight staff, and one witness. Allegation: Staff Spoke inappropriately to resident in care It is alleged that facility staff #1 (S1) verbally abused resident #1 (R1). Continued on LIC9099C Unsubstantiated Based on interviews conducted, four out of seven residents and eight out of eight staff denied the allegation staff spoke inappropriately to resident in care. Three out of seven residents could not confirm or deny the allegation. One witness confirmed the allegation. All staff, R4, R5, R6, and R7 stated they have never heard or observed S1 speaking inappropriately to any residents. All staff stated they would report to the Executive Director or other agencies if they observed any staff say any obscene or inappropriate language. Based on observations on November 13, 2025, LPA did not observe any staff speak inappropriately to memory care residents. On January 30, 2026, LPA did not observe any staff speaking inappropriately to memory care residents. Based on record reviews, there are no records of S1 in regards to complaints, disciplinary actions, and facility charting notes stating S1 spoke inappropriately with R1. Based on Facility Charting Notes for R1 dated from September 22, 2025, to December 28, 2025, there are no notes stating that S1 spoke inappropriately or any complaints from R1 about S1 or any staff. Based on observations, interviews, and records review, LPA did not find sufficient evidence to support the above allegation that facility staff verbally abused a resident. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegation is Unsubstantiated. Exit interview was conducted, and a copy of the report was provided to Executive Director Maria Kauten.the state’s words, verbatim · CDSS document, Jan 30, 2026 · control 22-AS-20251107104044

Allegation investigated: Staff handled resident in care in a rough manner. Staff did not provide clean linens to residents in care. Staff did not clean resident rooms.

On January 30, 2026, Licensing Program Analyst (LPA) Edward Kim conducted a subsequent complaint visit to deliver complaint investigation findings. LPA met with Executive Director (ED) Maria Kauten and explained the purpose of today’s visit. The investigation consisted of the following: LPA Kim conducted a tour of the facility. LPA Kim obtained and reviewed copies of the resident and staff rosters, resident records which include the Physician’s Reports, Appraisal/Needs and Services Plans, and other pertinent records for five staff. LPA conducted interviews with seven residents and eight staff. Allegation: Staff handled resident in care in a rough manner. It is alleged that staff #1 (S1) and staff #2 (S2) are rough with a resident especially during their shower time. A resident is to be known to be screaming during their shower time. Continued on LIC9099C Unsubstantiated Based on interviews conducted, four out of seven residents and eight out of eight staff denied the allegation. Two out of three residents interviewed could not confirm or deny the allegation. All staff, R4, R5, R6, and R7 stated they have not observed or heard any residents being handled in a rough manner. R4, R5, R6, and R7 stated they have not been handled in a rough manner by S1 and S2 during their shower time. Based on record reviews, there are no records of any disciplinary actions or complaints from the facility for S1 and S2. There are no incident reports related to R1 with S1 and S2 handling their shower time. Charting Notes for R1 dated from October 9, 2025 to November 29, 2025, do not note any injuries with a result from staff scrubbing too hard during shower times. Based on observations, LPA Kim did not observe any screaming residents during their time at the facility because they were handled in a rough manner. Allegation: Staff did not provide clean linens to residents in care. It is alleged that the staff in the memory care unit do not change the soiled linens in a resident’s room. Based on record review, LPA observed the cleaning schedule for the facility. Resident rooms are cleaned by the housekeepers once a week based on their designated areas. Based on observations, LPA inspected and visited the following rooms: 102, 104, 109, 112, 119, 125, 129, 209, 218, and 307. LPA observed these rooms to have clean linens during the inspection. Based on interviews conducted, four out of seven residents and eight out of eight staff denied the allegation. Three out of seven residents could not confirm or deny the allegation. All staff, R4, R5, R6, and R7 stated they have clean linens and if they get soiled linens the staff provides new linens and clean the soiled linens the same day. Staff stated they would take the soiled clothes and linens, then proceed to place it in the bag with the resident’s name and room number. Anything they need to put in the trash, they would take out immediately. All staff stated they would check the resident’s room at least once a day, at the end of their shift, to see if there was any need to clean up anything in the room. Allegation: Staff did not clean resident rooms. It is alleged that the staff in the memory care unit do not take out the trash. Continued on LIC9099C Based on record review, LPA observed the cleaning schedule for the facility. Resident rooms are cleaned by the housekeepers once a week based on their designated areas. Based on observations, LPA inspected and visited the following rooms: 102, 104, 109, 112, 119, 125, 129, 209, 218, and 307. LPA observed these rooms to be clean with no trash or litter throughout the bedroom. When a common area bathroom was a mess after a person who reported it, LPA observed staff immediately call in the housekeeping staff to clean the common bathroom. Housekeeping came within 2 minutes to go and clean up the common area bathroom. Based on interviews conducted, four out of seven residents and eight out of eight staff denied the allegation. Three out of seven residents could not confirm or deny the allegation. All staff, R3, R4, R5, R6, and R7 stated that the facility regularly cleans the bedrooms. All residents stated that the staff come in multiple times throughout the day to clean up trash. The caregivers stated it was their responsibility to make sure at least by the end of the shift they take out the trash and make sure the room was clean before they left. Based on the information gathered, there is no sufficient evidence to confirm the above allegation. Based on observations, interviews, and records review, LPA did not find sufficient evidence to support the above allegations that staff handled resident in care in a rough manner, staff did not provide clean linens to residents in care, and staff did not clean resident rooms. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are Unsubstantiated. Exit interview was conducted a copy of the report was provided to Executive Director Maria Kauten.the state’s words, verbatim · CDSS document, Jan 30, 2026 · control 22-AS-20251110103951

Type of visit: Required - 1 Year

On January 30, 2026, 8:40 AM, Licensing Program Analyst (LPA) Edward Kim conducted an unannounced required 1-Year annual visit using the CARE Inspection Tool. Upon arrival at the facility, LPA Kim met with Executive Director (ED) Maria Kauten and explained the purpose of the visit. The facility is licensed to operate for one hundred fifty-two (152) nonambulatory residents of which eight (8) may be bedridden and have a hospice waiver for fifteen (15) residents. The facility is a three-story structure and consists of the following: one hundred and one (101) resident bedrooms, nine (9) offices, one hundred and ten (110) bathrooms, living area, two dining areas, bar and lounge, TV room, kitchen, bistro, great area, theater room, fitness center, massage room, general outdoor patio area, outdoor dining courtyard, dog park, and a memory care outdoor patio area. LPA Kim toured inside and outside of the physical plant with ED Kauten. There were no obstructions on the premises. There are two small fountains in the general outdoor courtyard and a small fountain in the Memory Care Courtyard. All rooms were inspected. Beds and bedding supplies were in good condition, adequate lighting was provided, a chair, storage for each resident’s personal belongings was observed. Bed linens, comforters, and bath towels were adequately stocked at the time of visit. The following Resident’s rooms were inspected: Resident Room 104, Resident Room 112, Resident Room 114, Resident Room 123, Resident Room 129, Resident Room 212, Resident Room 224, Resident Room 230, Resident Room 312, Resident Room 320, and Resident Room 331. Bathrooms were found to be within Title 22 regulations and were clean and operational. The water temperature measured at 111.1 degrees F to 115.7 degrees F. A comfortable temperature of 74 degrees F was maintained in the facility. Evaluation Report Continues on LIC 809-C LPA Kim observed the facility to be sanitary and appropriately furnished at the time of visit. Storage areas for personal hygiene, cleaning supplies, toxins, and sharps objects were stored and not accessible to residents. The kitchen was inspected and there is a two-day supply of perishable and seven-day supply of non-perishable food available and maintained properly. Emergency food, emergency water, and emergency supplies were stored in the kitchen and staff emergency work room. The facility has twenty-one (21) fire extinguishers that were charged, mounted throughout the facility, and serviced on October 9,2025. During the visit, LPA Kim observed the facility's infection control practices, plan of operation, and screening protocols for visitors, staff, and residents. LPA observed the facility has a 30-day supply of Personal Protective Equipment (PPE). All mandated inspection control posters were posted. The smoke detectors and carbon monoxide detectors were inspected by Calbuilding Systems on October 9, 2025. A working telephone (714-869-1940) and an internet capable devices for video teleconferencing purposes remains available. LPA observed the facility Evidence of Liability Insurance was effective 08/06/2025, and expires on 08/06/2026. Emergency Drills were conducted quarterly and last conducted on January 21, 2026. LPA Kim conducted an audit of twelve (12) resident files (R1-R12), nine (9) staff files (S1-S9), and medication and medication administration record were all in order and complete. LPA Kim conducted five (5) staff interviews and eight (8) resident interviews. No deficiencies were cited during this visit. An exit interview was conducted, and a copy of this report was provided to Executive Director Maria Kauten.the state’s words, verbatim · CDSS document, Jan 30, 2026

Allegation investigated: Resident was severely dehydrated due to neglect Resident was severely malnutrition due to neglect Resident not changed timely Due to neglect, Resident received a fracture while in care

Licensing Program Analyst (LPA) Cheyenne Ratajczak arrived at the facility unannounced and met with Executive Director (ED) Maria Kauten 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*** Unsubstantiated Allegation: Resident was severely dehydrated due to neglect- Unsubstantiated Facility staff, including two (2) Licensed Vocation Nurses (LVN’s) who cared for Resident #1 (R1) all stated R1 was provided juice, milk and water with each meal. In addition, R1’s family provided them with a small refrigerator in their room that was stocked with water. There are also beverages offered in the dining room, bar and Bistro area all day and R1 was ambulatory and had access to these areas. Staff indicated that R1 could express their needs and would ask staff when they needed something. None of the staff ever observed any signs or symptoms of R1 being dehydrated. Medical Records for R1’s visit on 03/11/2023 states they were treated with IV fluids due to signs of clinical dehydration. However, it does not provide any other information. R1 had a second visit on 03/12/2023 and there was no documentation of dehydration. Allegation: Resident was severely malnutrition due to neglect- Unsubstantiated Facility staff, including two LVN’s who cared for R1 all stated R1 ate well. However, R1 would occasionally say they were full and not finish their meal because they did not like what was being served. None of the staff who cared for R1 observed any signs of R1 being malnourished. In addition, R1 was able to communicate their needs and ask staff for what they need. In February of 2023, staff voice concerns of R1 losing weight which was brought to the attention of R1s physician who prescribed R1 medication to enhance their appetite. R1 was sent back to the hospital on 03/12/2023, due to low blood pressure reading again. R1 was diagnosed with severe protein calorie malnutrition. However, there is a notation that states this condition was first noted on 03/18/2023, six days after R1’s admission to the hospital, and it is unknown if condition was present at admission on 03/12/2023. **Report continued on 9099-C** Allegation: Resident not changed timely- Unsubstantiated Interviews with staff indicated that caregivers are assigned residents at the beginning of their shift, which means they are to assist with those residents with incontinence care needs. Staff interviews further revealed that residents are assisted with incontinence care every two hours or as needed. Residents will also utilize their pendant if they need assistance between that time. Resident interviews revealed that staff meet their incontinence needs. Residents indicated they feel comfortable with staff and will use their pendants or staff will just check on them. Allegation: Due to neglect, Resident received a fracture while in care- Unsubstantiated According to facility staff, R1 had unwitnessed fall while at the facility. The first one in November 2022 and the second one in January 2023. R1 was evaluated by facility LVN on both occasions. R1 had no visible injuries, complaints of pain and when they were helped to their feet, they were able to walk without any complaints or signs of pain. Staff indicated that R1 was walking without assistances or signs of pain up until the day they were first transported the hospital on 03/11/2023. During R1’s visit to the hospital on 03/11/2023, record review indicated R1 had a Severe T8 Compression Fracture. Records reviewed did not contain any further details or how the fracture may have occurred or was treated. R1 had a follow up visit at the hospital on 04/04/2023. R1 was diagnosed with “Chronic appearing T8 Compression Fracture” Interview with medical professional revealed it is common for someone R1s age to suffer compression fractures and there is no way for them to determine the age of the injury or when it may have occurred. Based on interviews conducted and records reviewed, the preponderance of evidence standards have not been met. Therefore, the above allegations are found to be UNSUBSTANTIATED. A finding that a complaint allegation 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 was conducted. A copy of this report was provided and appeal rights provided.the state’s words, verbatim · CDSS document, Jul 9, 2025 · control 22-AS-20230328105245

Type of visit: Case Management - Other

On this day, Licensing Program Analyst (LPA) Kevin Saborit-Guasch made an unannounced visit to the facility for the purpose of following up on the investigation of one complaint filed regarding the previous licensed entity at this present location, prior to the initial licensing of the present facility. Complaint is referenced as follows: 22-AS-20210818113839, filed on August 18, 2021. The complaint was filed in regard to licensed facility Oakmont of Fullerton - 306005795 which is a distinct entity from the present facility. During the investigation, LPA attempted to conduct an additional interview with a facility resident, who declined to be interviewed. An exit interview was conducted and a copy of this report was provided to a facility representative.the state’s words, verbatim · CDSS document, Mar 10, 2025

Type of visit: Case Management - Other

On this day, Licensing Program Analyst (LPA) Kevin Saborit-Guasch made an unannounced visit to the facility for the purpose of following up on the investigation of four complaints filed regarding the previous licensed entity at this present location, prior to the initial licensing of the present facility. Complaints are referenced as follows: - 22-AS-20210818113839, filed on August 18, 2021 - 22-AS-20210917092143, filed on September 17, 2021 - 22-AS-20220822143206, filed on August 22, 2022 - 22-AS-20220906140344, filed on September 6, 2022. All four complaints have been filed against licensed facility Oakmont of Fullerton - 306005795 which is a distinct entity from the present facility. During the investigation, LPA requested multiple resident records and conducted or attempted to conduct staff and resident interviews. An exit interview was conducted and a copy of this report was provided to a facility representative.the state’s words, verbatim · CDSS document, Feb 12, 2025

Type of visit: Case Management - Other

On December 18, 2024, at 4:30pm, Licensing Program Analyst (LPA) Edward Kim conducted a Case Management visit following up an email self-reporting an incident that occurred at the facility. LPA Kim was greeted and granted entry by Concierge Lexine Toya. LPA Kim met with Executive Director (ED) Maria Kauten and explained the purpose of the visit. During today’s inspection, LPA Kim conducted health and safety check and conducted interviews with ED Kauten, Business Office Director Laura Britain, and Kitchen staff. LPA observed the dishwasher in the kitchen where the incident occurred. The fire department provided a report number F2415915. The cause of the fire was the dishwasher's electric motor melted and burned inside of the dishwasher unit. The fire has been contained and no staff and residents were hurt. No staff or residents were sent to the hospital. Based on observations and interviews, there are no health and safety concerns at the facility. A copy of the fire report, Personnel Report, Resident Roster, and other pertinent documents were provided to the LPA. An exit interview was conducted and a copy of this report was given to Executive Director Maria Kauten.the state’s words, verbatim · CDSS document, Dec 18, 2024

Type of visit: Required - 1 Year

On November 5, 2024, at 8:45am, Licensing Program Analyst (LPA) Edward Kim conducted an unannounced required 1-Year annual visit using the CARE Inspection Tool. Upon arrival at the facility, LPA Kim was greeted and granted entry by Concierge Jessica Ramirez. Executive Director (ED) Maria Kauten arrived the facility around 11:00am. The facility is licensed to operate for one hundred fifty-two (152) nonambulatory residents of which eight (8) may be bedridden and have a hospice waiver for fifteen (15) residents. The facility is a three story structure and consists of the following: one hundred and one (101) resident bedrooms, nine (9) offices, one hundred and ten (110) bathrooms, living area, two dining areas, bar and lounge, TV room, kitchen, bistro, great area, theater room, fitness center, massage room, general outdoor patio area, outdoor dining courtyard, dog park, and a memory care outdoor patio area. LPA Kim toured inside and outside of the physical plant with Business Office Director Laura Britain and Health Service Director Jhoana Salmi. There were no obstructions on the premises. There are two small fountains in the general outdoor courtyard and a small fountain in the Memory Care Courtyard. All rooms were inspected. Beds and bedding supplies were in good condition, adequate lighting was provided, a chair, storage for each resident’s personal belongings was observed. Bed linens, comforters, and bath towels were adequately stocked at the time of visit. The following Resident’s rooms were inspected: Resident Room 105, Resident Room 115, Resident Room 119, Resident Room 212, Resident Room 225, Resident Room 229, Resident Room 231, Resident Room 307, Resident Room 315, and Resident Room 323. Bathrooms were found to be within Title 22 regulations and were clean and operational. The water temperature measured at 110.3 degrees F to 113.9 degrees F. A comfortable temperature of 72 degrees F was maintained in the facility. Evaluation Report Continues on LIC 809-C LPA Kim observed the facility to be sanitary and appropriately furnished at the time of visit. Storage areas for personal hygiene, cleaning supplies, toxins, and sharps objects were stored and not accessible to residents. The kitchen was inspected and there is a two-day supply of perishable and seven-day supply of non-perishable food available and maintained properly. Emergency food, emergency water, and emergency supplies were stored in the kitchen and staff emergency work room. The facility has twenty-one (21) fire extinguishers that were charged, mounted throughout the facility, and serviced on November 5, 2024. During the visit, LPA Kim observed the facility's infection control practices, plan of operation, and screening protocols for visitors, staff, and residents. LPA observed the facility has a 30-day supply of Personal Protective Equipment (PPE). All mandated inspection control posters were posted. The smoke detectors and carbon monoxide detectors were inspected by Calbuilding Systems on October 17, 2024. A working telephone (714-869-1940) and an internet capable devices for teleconferencing purposes remains available. LPA observed the facility Evidence of Liability Insurance was effective 12/31/2023 and expires on 12/31/2024. LPA Kim conducted an audit of ten (10) resident files (R1-R10), ten (10) staff files (S1-S10), and medication and medication administration record were all in order and complete. LPA Kim conducted five (5) staff interviews and four (4) resident interviews. No deficiencies were cited during this visit. An exit interview was conducted, and a copy of this report was provided to Executive Director Maria Kauten.the state’s words, verbatim · CDSS document, Nov 5, 2024

Allegation investigated: Facility is charging a deceased resident's family after belonging were retrieved

Licensing Program Analysts (LPAs) Celine De Perio and Rose Ruppert conducted an unannounced 10-day visit to the facility for the complaint and to deliver the findings. LPAs explained the purpose of today's visit, and was greeted by Executive Director (ED) Maria Kauten. During the investigation, LPAs toured the physical plant of the facility, conducted interviews, and requested copies of pertinent records reviewed. It was alleged that facility is charging a deceased resident's family after belonging were retrieved.1 out of 1 staff interview conducted stated that resident (R1) passed away on January 28, 2024 and that the facility had accidentally charged the resident's family from February 1, 2024 to February 6, 2024. Upon the facility discovering that R1's family was getting charged, a reimbursement check to R1's family was issued on May 9, 2024 for the amount of $917.13 for the time frame of February 1, 2024 to February 6, 2024. Unsubstantiated Based on LPA’s interviews which were conducted, review of documents obtained, and observations, LPAs are unable to ascertain if the allegation occurred as reported. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove or refute the alleged violation occurred; therefore, this allegation is deemed UNSUBSTANTIATED. LPAs conducted an interview with ED Kauten. A copy of this report was provided and explained.the state’s words, verbatim · CDSS document, May 16, 2024 · control 22-AS-20240507103000

Type of visit: Case Management - Other

Licensing Program Analyst (LPA) Jessica Cho and the Department's Investigations Branch Investigator (IBI) Hector Quintanar arrived unannounced for the purpose to conduct a case management visit at the facility. LPA and IBI interviewed Staff #1 (S1) in connection to Complaint Control Number: 22-AS-20231116152802 unrelated to this facility. An exit interview was conducted with Executive Director Maria Kauten, and copy of this report and the LIC811 were provided at the end of the visit.the state’s words, verbatim · CDSS document, Feb 1, 2024