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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 107209036
Report Date: 07/14/2025
Date Signed: 07/15/2025 08:05:06 AM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1314 E SHAW AVE
FRESNO, CA 93710
This is an official report of an unannounced visit/investigation of a complaint received in our office on
04/30/2025 and conducted by Evaluator Katie Brown
PUBLIC
COMPLAINT CONTROL NUMBER: 24-AS-20250430083718
FACILITY NAME:OAKMONT OF NORTH FRESNOFACILITY NUMBER:
107209036
ADMINISTRATOR:SETTY, HEIDIFACILITY TYPE:
740
ADDRESS:5605 N GATES AVETELEPHONE:
(559) 277-5959
CITY:FRESNOSTATE: CAZIP CODE:
93722
CAPACITY:122CENSUS: 84DATE:
07/14/2025
UNANNOUNCEDTIME BEGAN:
03:30 PM
MET WITH:Heidi SettyTIME COMPLETED:
06:45 PM
ALLEGATION(S):
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Staff leave resident soiled causing skin rash
Staff do not follow Physician's Orders
Staff do not ensure resident's hygiene needs are met
Staff do not allow resident visitation
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Katie Brown arrived at the facility unannounced to conduct a subsequent complaint visit and deliver complaint findings. LPA met with and explained the reason for the visit with Administrator (AD) Heidi Setty.

During the visit, LPA observed Resident (R1) in the common area. LPA observed R1's apartment, conducted interviews and reviewed records. The Department investigated the allegations listed above:

Staff leave resident soiled causing skin rash: Per Service Plan dated 4/19/25 R1 uses incontinence supplies and frequently refuses staff assistance with care including toileting and bathing. Review of Medication Record reveals that R1 refuses taking medications including use of tpoical creams often. Staff interviews have conflicting reporting on R1's compliance with activities of daily living.

See LIC9099C for continuation of this report
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Sergiy Pidgirny
LICENSING EVALUATOR NAME: Katie Brown
LICENSING EVALUATOR SIGNATURE:

DATE: 07/14/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/14/2025
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 4
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1314 E SHAW AVE
FRESNO, CA 93710
This is an official report of an unannounced visit/investigation of a complaint received in our office on
04/30/2025 and conducted by Evaluator Katie Brown
PUBLIC
COMPLAINT CONTROL NUMBER: 24-AS-20250430083718

FACILITY NAME:OAKMONT OF NORTH FRESNOFACILITY NUMBER:
107209036
ADMINISTRATOR:SETTY, HEIDIFACILITY TYPE:
740
ADDRESS:5605 N GATES AVETELEPHONE:
(559) 277-5959
CITY:FRESNOSTATE: CAZIP CODE:
93722
CAPACITY:122CENSUS: DATE:
07/14/2025
UNANNOUNCEDTIME BEGAN:
03:30 PM
MET WITH:Heidi SettyTIME COMPLETED:
06:45 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Staff are mishandeling resident medications
Staff do not ensure resident has adequate hygiene supplies
Staff do not ensure resident's safety from another resident
Facility does not provide resident adequate meals
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Licensing Program Analyst (LPA) Katie Brown arrived at the facility unannounced to conduct a subsequent complaint visit and deliver complaint findings. LPA met with and explained the reason for the visit with Administrator (AD) Heidi Setty.

During the visit, LPA observed Resident (R1) in the common area. LPA observed R1's apartment, conducted interviews and reviewed records. The Department investigated the allegations listed above:

Staff are mishandeling resident medications: Record review of R1's medications and Physicians Orders was conducted. Review of R1's file confirmed staff communication with R1's Physician, Pharmacy and Public Guardian related to medication changes and concerns.

See LIC9099C for continuation of this report

Unfounded
Estimated Days of Completion:
SUPERVISORS NAME: Sergiy Pidgirny
LICENSING EVALUATOR NAME: Katie Brown
LICENSING EVALUATOR SIGNATURE:

DATE: 07/14/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/14/2025
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 4
Control Number 24-AS-20250430083718
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1314 E SHAW AVE
FRESNO, CA 93710
FACILITY NAME: OAKMONT OF NORTH FRESNO
FACILITY NUMBER: 107209036
VISIT DATE: 07/14/2025
NARRATIVE
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Page 2 - Unfounded
This Department investigated the following allegations:

Staff do not ensure resident has adequate hygiene supplies: On 5/6, 7/1 and 7/14/25 R1's apartment was observed to have hygiene supplies. Hygiene items such as tooth and hair brushes were well maintained and properly stored. Staff were interviewed and consistently stated that when additional supplies are needed, they would communicate with the Med Tech or Nurse to contact the Responsible Party.

Staff do not ensure resident's safety from another resident: During the interview with the RP, it was noted that this allegation was noted in a previously investigated complaint. Additionally, R1's Service Plan dated 4/19/2025 notes suspicious or accusatory behavior related to distrust of men in the past. This behavior has not been reported by staff since moving to a new, private room.

Facility does not provide resident adequate meals: During visits at the facility on 5/6 and 7/1/25, R1 was observed eating lunch once, dinner twice in the dining room and multiple snacks in the common area with other residents. Snacks and beverages provided by family were also observed available in R1's room. Based on interviews and record reviews, R1 has memory loss and may not recall what was served or eaten at meals. Service plan and Physician Report also note Dementia and Memory Impairment.

This Agency has investigated the allegations listed above. We have found that the allegations are UNFOUNDED, therefore we have dismissed the allegations.

There were no citations issued

An exit interview was conducted and a copy of this report was provided.
SUPERVISORS NAME: Sergiy Pidgirny
LICENSING EVALUATOR NAME: Katie Brown
LICENSING EVALUATOR SIGNATURE:

DATE: 07/14/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/14/2025
LIC9099 (FAS) - (06/04)
Page: 4 of 4
Control Number 24-AS-20250430083718
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1314 E SHAW AVE
FRESNO, CA 93710
FACILITY NAME: OAKMONT OF NORTH FRESNO
FACILITY NUMBER: 107209036
VISIT DATE: 07/14/2025
NARRATIVE
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Page 2
This Department investigated the following allegations:

Staff do not follow Physician's Orders: Copies of R1's Physicians orders were provided to this Department for the purpose of this complaint investigation on 5/6/25 by the facility. R1's Public Guardian also provided a statement of R1's medications. The Reporting Party has also provided documents of medications which have been ordered over the span of multiple years by different physicians and specialists. Interviews reveal that the facility conducts communication related to R1's medication and medical changes with the court appointed Public Guardian.

Staff do not ensure resident's hygiene needs are met: R1 was observed on 5/6, 7/1 and 7/14/25 at the community. On 5/6 and and 7/1/25 R1 had been assisted with a shower. All dates listed above, R1 was observed in clean clothing wearing appropriate shoes. R1 was noted to be in the activity or seating area. R1's Service Plan dated 4/19/25 notes that R1 frequently refuses assistance with bathing or hygiene care.

Staff do not allow resident visitation: R1 has a court appointed Public Guardian. Record review and Interviews have been conducted which outline the visitation for R1. Multiple interviews were conducted related to R1's visitations and visitors at the facility, the reports were inconsistent. Email communication was provided by different parties involved in R1's care for review which provides documentation of the visitation agreement.

Based on interview and record review the above allegations are UNSUBSTANTIATED. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove that the alleged violations did or did not occur.

There were no citations issued.

An exit interview was conducted and a copy of this report was





SUPERVISORS NAME: Sergiy Pidgirny
LICENSING EVALUATOR NAME: Katie Brown
LICENSING EVALUATOR SIGNATURE:

DATE: 07/14/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/14/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 4