079201085-3-20-2026-15-AS-BFOG-DSXLVX-20260408090615

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 079201085
Report Date: 03/20/2026
Date Signed: 03/20/2026 04:48:40 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
08/25/2025 and conducted by Evaluator Alona Gomez

COMPLAINT CONTROL NUMBER: 15-AS-20250825145826

FACILITY NAME:	OAKMONT OF CONCORD		FACILITY NUMBER:	079201085
ADMINISTRATOR:	SOR, KIM S		FACILITY TYPE:	740
ADDRESS:	1401 CIVIC COURT		TELEPHONE:	(925) 798-4004
CITY:	CONCORD	STATE: CA	ZIP CODE:	94520
CAPACITY:	121	CENSUS: 90	DATE:	03/20/2026
		UNANNOUNCED	TIME BEGAN:	02:20 PM
MET WITH:	Executive Director, San Sor		TIME COMPLETED:	05:00 PM

ALLEGATION(S):

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Facility is in disrepair
Facility is not adequetly staffed

INVESTIGATION FINDINGS:

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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

Estimated Days of Completion:

SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Alona Gomez
LICENSING EVALUATOR SIGNATURE:	DATE: 03/20/2026

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/20/2026

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 15-AS-20250825145826

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: OAKMONT OF CONCORD	FACILITY NUMBER: 079201085
	VISIT DATE: 03/20/2026

NARRATIVE

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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.

SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Alona Gomez
LICENSING EVALUATOR SIGNATURE:	DATE: 03/20/2026

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/20/2026

LIC9099 (FAS) - (06/04)

Page: 4 of 5

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
08/25/2025 and conducted by Evaluator Alona Gomez

COMPLAINT CONTROL NUMBER: 15-AS-20250825145826

FACILITY NAME:	OAKMONT OF CONCORD		FACILITY NUMBER:	079201085
ADMINISTRATOR:	SOR, KIM S		FACILITY TYPE:	740
ADDRESS:	1401 CIVIC COURT		TELEPHONE:	(925) 798-4004
CITY:	CONCORD	STATE: CA	ZIP CODE:	94520
CAPACITY:	121	CENSUS: 90	DATE:	03/20/2026
		UNANNOUNCED	TIME BEGAN:	02:20 PM
MET WITH:	Executive Director, San Sor		TIME COMPLETED:	05:00 PM

ALLEGATION(S):

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Facility left residents unattended
Facility did not ensure residents receive meals as scheduled
Residents needs and services are not being met

INVESTIGATION FINDINGS:

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Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Alona Gomez
LICENSING EVALUATOR SIGNATURE:	DATE: 03/20/2026

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/20/2026

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

Page: 2 of 5

Control Number 15-AS-20250825145826

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: OAKMONT OF CONCORD	FACILITY NUMBER: 079201085
	VISIT DATE: 03/20/2026

NARRATIVE

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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.

SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Alona Gomez
LICENSING EVALUATOR SIGNATURE:	DATE: 03/20/2026

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/20/2026

LIC9099 (FAS) - (06/04)

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Citations on this Visit Report are Under Appeal!

Control Number 15-AS-20250825145826

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: OAKMONT OF CONCORD	FACILITY NUMBER: 079201085
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 03/20/2026

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Under Appeal Type B 03/27/2026 Section Cited CCR 87303(a)	1 2 3 4 5 6 7	(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:	1 2 3 4 5 6 7	By POC facility agrees to test all call buttons and ensure they are operational and notify CCLD
	8 9 10 11 12 13 14	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 care	8 9 10 11 12 13 14
Under Appeal Type B 03/27/2026 Section Cited CCR 87411(a)	1 2 3 4 5 6 7	(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:	1 2 3 4 5 6 7	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.
	8 9 10 11 12 13 14	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 care	8 9 10 11 12 13 14

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: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Alona Gomez
LICENSING EVALUATOR SIGNATURE:	DATE: 03/20/2026

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/20/2026

LIC9099 (FAS) - (06/04)

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