<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 019200873
Report Date: 05/29/2026
Date Signed: 05/29/2026 03:33:31 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
OAKLAND ASC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
This is an official report of an unannounced visit/investigation of a complaint received in our office on
01/28/2026 and conducted by Evaluator David Doidge
COMPLAINT CONTROL NUMBER: 15-AS-20260128140045
FACILITY NAME:POINT AT ROCKRIDGE, THEFACILITY NUMBER:
019200873
ADMINISTRATOR:REDDY, ANNAFACILITY TYPE:
740
ADDRESS:4500 GILBERT STREETTELEPHONE:
(510) 658-9266
CITY:OAKLANDSTATE: CAZIP CODE:
94611
CAPACITY:186CENSUS: DATE:
05/29/2026
UNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:TIME COMPLETED:
11:30 AM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Staff did not seek emergency care services for resident in a timely manner
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
On 05/29/2026 at 11:00 AM, Licensing Program Analyst (LPA) David Doidge arrived unannounced to deliver findings in regards to the allegation above. LPA met with Executive Director Anna Reddy and explained the purpose of the visit.

During the investigation, LPA collected the following documents: Resident Roster, Staff Roster, List of staff that have left since November, Physician Report (LIC602), Appraisal Needs and Services, and the Identification and Emergency Information form for four (4) residents. The Department also obtained a Death Certificate, Coroner’s Report, and a Police Report for R1. The Department interviewed S1, S2, S3, S4, S5, S6, S7, S8, R2, and R3.

Allegation: Staff did not seek emergency care services for resident in a timely manner

Continued on LIC9099-C
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: David Doidge
LICENSING EVALUATOR SIGNATURE:

DATE: 05/29/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/29/2026
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 6
Control Number 15-AS-20260128140045
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
OAKLAND ASC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME: POINT AT ROCKRIDGE, THE
FACILITY NUMBER: 019200873
VISIT DATE: 05/29/2026
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
Continued from LIC9099

Investigation Findings: It was reported to the department that staff waited approximately 60 minutes prior to calling 911. S3 stated S3 noticed at 8:30 AM that the bathroom door where R1 was found was locked. S3 returned at 9:30 AM to open and clean the bathroom when S3 found R1 unresponsive and yelled for someone to call 911. S8 stated S3 informed S8 about 9:50 AM that S3 found R1 unresponsive and to call 911. S6 reported hearing S3 call for someone to call for 911 and did so at 8:30 AM. According to the Oakland Fire Department (FD) Incident Report, the FD wasn’t notified of R1’s need for emergency services until approximately 10:21 AM. When asked by the FD why facility staff waited 60 minutes before calling 911, the Med Tech on duty was unable to explain, therefore the allegation is SUBSTANTIATED.

Based interviews conducted during investigation, the preponderance of evidence standard has been met; therefore, the above allegation is found to be SUBSTANTIATED.
Deficiency is cited from Title 22 California Code of Regulations (see LIC9099D). Failure to submit proof of correction by plan of correction due date and any repeat violation within 12 month period may result in an additional civil penalty.

Deficiency and plan and proof of correction were discussed with Executive Director Anna Reddy.

Exit interview conducted, Appeal Rights, and a copy this report provided.
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: David Doidge
LICENSING EVALUATOR SIGNATURE:

DATE: 05/29/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/29/2026
LIC9099 (FAS) - (06/04)
Page: 2 of 6
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
OAKLAND ASC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
This is an official report of an unannounced visit/investigation of a complaint received in our office on
01/28/2026 and conducted by Evaluator David Doidge
COMPLAINT CONTROL NUMBER: 15-AS-20260128140045

FACILITY NAME:POINT AT ROCKRIDGE, THEFACILITY NUMBER:
019200873
ADMINISTRATOR:REDDY, ANNAFACILITY TYPE:
740
ADDRESS:4500 GILBERT STREETTELEPHONE:
(510) 658-9266
CITY:OAKLANDSTATE: CAZIP CODE:
94611
CAPACITY:186CENSUS: DATE:
05/29/2026
UNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:TIME COMPLETED:
11:30 AM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Questionable death

Staff engaged in the misuse of the emergency 9-1-1 system
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
On 05/29/2026 at 11:30 AM, Licensing Program Analyst (LPA) David Doidge arrived unannounced to deliver findings in regards to the allegation above. LPA met with Executive Director Anna Reddy and explained the purpose of the visit.

During the investigation, LPA collected the following documents: Resident Roster, Staff Roster, List of staff that have left since November, Physician Report (LIC602), Appraisal Needs and Services, and the Identification and Emergency Information form for four (4) residents. The Department also obtained a Death Certificate, Coroner’s Report, and a Police Report for R1. The Department interviewed S1, S2, S3, S4, S5, S6, S7, S8, R2, and R3.

Allegation: Questionable death

Continued on LIC9099-C
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: David Doidge
LICENSING EVALUATOR SIGNATURE:

DATE: 05/29/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/29/2026
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 3 of 6
Control Number 15-AS-20260128140045
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
OAKLAND ASC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME: POINT AT ROCKRIDGE, THE
FACILITY NUMBER: 019200873
VISIT DATE: 05/29/2026
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
Continued from LIC9099
Investigation Findings: It was reported to the department that Neglect and Lack of Care by staff resulted in the death of resident. According to the Death Certificate, R1’s immediate cause of death was due to cardiopulmonary arrest, onset interval of minutes and coronary artery disease, onset interval of years. According to the coroner’s report, R1’s manner of death was natural, stemming from cardiopulmonary arrest and coronary artery disease. The coroner’s office reported that providing or seeking medical attention sooner would not have made a difference in the cause of R1’s death While it is believed that facility staff failed to perform, and/or properly perform CPR on R1 upon finding R1 unresponsive and non-breathing, there is no indication this resulted in R1’s death. Based on the Death Certificate findings, the allegation is UNSUBSTANTIATED.

Allegation: Staff engaged in the misuse of the emergency 9-1-1 system

Investigation Findings: It was reported to the department that the facility staff have judiciously used the 911 system for a wide array of calls, including running out of art supplies, residents being thirsty, or the inability of the residents to get in touch with staff for a simple aspirin, thus calling 911 for assistance. Normally, 911 crew are met with a shrug of the shoulder from staff during these calls. These types of calls can be categorized as an annoyance and/or abuse of the 911 system. LPA interviewed O1 on the phone, who stated that EMT will come out to the facility for calls that are determined, upon arrival, to be non-emergency and will vary from things like someone fell and no one wanted to lift the person, to simple things that a person acting as a “Good Samaritan” could assist someone with. LPA asked what was meant by “Good Samaritan”, O1 answered that a person acting in good faith to assist someone cannot not punished legally if there are adverse outcomes. O1 feels staff in the facility should act in that nature rather than calling 911 for “every little thing.”. S1 informed LPA staff are taught to call 911 every fall and for any situation they deem an emergency. S1 also informed LPA that staff are usually not informed when a resident calls 911 on his or her own nor does they facility request that residents inform staff before calling 911. S2 confirmed that staff in the facility are not clinically trained and would rather that staff err on the side of caution and call than to assist and further harm a resident in need, as S2 confirmed staff are trained to do. S3 greets individuals coming into the facility. S3 does not ask 911 responders for the reason they are coming in. S3 is usually aware that 911 was called, unless it was a resident.



Continued on LIC9099-C
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: David Doidge
LICENSING EVALUATOR SIGNATURE:

DATE: 05/29/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/29/2026
LIC9099 (FAS) - (06/04)
Page: 4 of 6
Control Number 15-AS-20260128140045
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
OAKLAND ASC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME: POINT AT ROCKRIDGE, THE
FACILITY NUMBER: 019200873
VISIT DATE: 05/29/2026
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
Continued from LIC9099-C

S4 is aware that at times residents have called 911 without staff being informed, but S4 has been instructed to not stop a resident from calling 911. S5 and S6 assist residents in the activities room. S5 and S6 say paramedics have never needed to stop a class to assist residents. S3, S4, S5 and S5 all told LPA that 911 is called, per facility policy, every time there is a fall and overtime the resident requiring assistance is deemed to need assistance beyond the scope of training that staff member has. R1, R2 and R3 all stated they had never called 911 on their own. R1, R2 and R3 all feel that staff and residents should be able to call 911 without seeking approval first. Based on interviews the above allegation is UNSUBSTANTIATED.

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.

No deficiencies were cited during this inspection.

Exit interview conducted and a copy of this report provided.

SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: David Doidge
LICENSING EVALUATOR SIGNATURE:

DATE: 05/29/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/29/2026
LIC9099 (FAS) - (06/04)
Page: 5 of 6
Control Number 15-AS-20260128140045
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
OAKLAND ASC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: POINT AT ROCKRIDGE, THE
FACILITY NUMBER: 019200873
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/29/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
06/12/2026
Section Cited
CCR
87465(g)
1
2
3
4
5
6
7
The licensee shall immediately telephone 9-1-1 …an imminent threat to a resident’s health…apparent life-threatening medical crisis...

This requirement was not met as evidence by:
1
2
3
4
5
6
7
By POC date, Licensee will do an in service training to all staff on the regulation regarding calling 911, and submit a to the facility and submit proof of training to LPA.
8
9
10
11
12
13
14
Based on interviews and file review, the licensee did not comply with the section cited above by staff not immediately calling 911 when a resident was in need of emergency care which poses a potential health and safety risk to persons in care.
8
9
10
11
12
13
14
1
2
3
4
5
6
7
1
2
3
4
5
6
7
1
2
3
4
5
6
7
1
2
3
4
5
6
7
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: David Doidge
LICENSING EVALUATOR SIGNATURE:

DATE: 05/29/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/29/2026
LIC9099 (FAS) - (06/04)
Page: 6 of 6