198603479-5-20-2025-28-AS-WSHO-DHWSQZ-20250623140533

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198603479
Report Date: 05/20/2025
Date Signed: 05/20/2025 03:13:36 PM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
MONTEREY PARK ASC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

This is an official report of an unannounced visit/investigation of a complaint received in our office on
05/14/2025 and conducted by Evaluator Mary G Flores

PUBLIC

COMPLAINT CONTROL NUMBER: 28-AS-20250514152656

FACILITY NAME:	OAKMONT OF WHITTIER		FACILITY NUMBER:	198603479
ADMINISTRATOR:	RUNGE, ADRIANE		FACILITY TYPE:	740
ADDRESS:	13617 WHITTIER BLVD.		TELEPHONE:	(562) 693-8222
CITY:	WHITTIER	STATE: CA	ZIP CODE:	90605
CAPACITY:	97	CENSUS: 69	DATE:	05/20/2025
		UNANNOUNCED	TIME BEGAN:	09:22 AM
MET WITH:	Adriane Runge - Executive Director		TIME COMPLETED:	03:30 PM

ALLEGATION(S):

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Facility staff did not dispense resident's medications as prescribed
Facility staff handled resident(s) in a rough manner
Facility staff yelled at resident(s)
Facility staff did not observe proper food service sanitation practices
Facility staff did not safeguard resident's personal belongings

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Mary Flores conducted an unannounced compliant visit regarding the above allegations. LPA met with Adriane Runge Administrator and explained the reason for the visit.

The investigation consisted of the following: LPA requested a staff/resident roster. LPA interviewed 7 residents and 7 staff. LPA conducted a tour of the dementia unit and observed the dining room area and medication room. LPA reviewed medication for 4 residents. LPA reviewed file for resident #1(R1) and requested a copy of admission agreement, medical assessment, individual care plan, medication sheet, physician’s orders, resident personal property and valuables, preplacement assessments, behavioral expression appraisal, charting notes, and incident report.

The investigation revealed the following: Regarding allegation: Facility staff did not dispense R1’s medications as prescribed. (CONTINUED ON LIC 9099C)

Unsubstantiated

Estimated Days of Completion:

NAME OF LICENSING PROGRAM MANAGER: Wei Siew Ho
NAME OF LICENSING PROGRAM ANALYST: Mary G Flores
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 05/20/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/20/2025

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 28-AS-20250514152656

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
MONTEREY PARK ASC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: OAKMONT OF WHITTIER	FACILITY NUMBER: 198603479
	VISIT DATE: 05/20/2025

NARRATIVE

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It is alleged staff gave R1 doses of medication without doctor’s consent. Interviews conducted with residents revealed 4 out of 7 residents stated their medication is provided as prescribed and 3 out of 7 residents were not able to provide information due to cognitive skills. Interviews with staff revealed medication technicians provide medication as prescribed by the physician. Documents review revealed, on 3/11/25 a medication clarification sheet was signed by nurse practitioner listing two orders of quetiapine, one for 25mg and another for 50mg. Medication administration record notes the same medications listed on medication clarification. Charting notes revealed, on 5/12/25 and 5/13/25 R1’s responsible party shared concerns about the medication dosage to medication technician. On 5/13/25 facility staff contacted nurse practitioner to address R1’s responsible party concerns. On 5/14/25 facility staff received new order of medication per R1’s responsible party request. Medication review did not reveal medication errors. Although the allegation may have happened the facility staff were providing medication as prescribed. Facility noted R1’s responsible party concern and address it with physician.

Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is UNSUBSTANTIATED.

Regarding allegations: Facility staff handled residents in a rough manner and Facility staff yelled at resident. It is alleged staff aggressively sat a resident down and yelled at another resident. Interviews conducted with residents revealed 7 out of 7 residents stated that facility staff treat them well and respectfully. Interviews with staff revealed staff have not observed any other staff treat the residents in an aggressive manner or yelling at residents. Per administrator there have not been any incidents of staff treating residents disrespectfully report it. Training on Communication; Courtesy was provided to staff #2 on 4/22/25.

Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is UNSUBSTANTIATED.

Regarding allegation: Facility staff did not observe proper food service sanitation practices. It is alleged staff serve food with dirty hands and without gloves. Interviews with residents revealed 4 out of 7 residents stated staff take measurements to observe sanitation practices and 3 out of 7 residents were unable to answer due to cognitive skills. Interviews with staff revealed staff use gloves and hairnets to serve the food provided to the residents and practice hygiene while providing care. (CONTINUED ON LIC 9099C)

NAME OF LICENSING PROGRAM MANAGER: Wei Siew Ho
NAME OF LICENSING PROGRAM ANALYST: Mary G Flores
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 05/20/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/20/2025

LIC9099 (FAS) - (06/04)

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Control Number 28-AS-20250514152656

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
MONTEREY PARK ASC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: OAKMONT OF WHITTIER	FACILITY NUMBER: 198603479
	VISIT DATE: 05/20/2025

NARRATIVE

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Interviews with staff revealed staff use gloves and hairnets to serve the food provided to the residents and practice hygiene while providing care. Training on basic hand hygiene was provided on 6/10/24 and About Infection Control and Prevention on 6/8/24 was provided to staff #2.

Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is UNSUBSTANTIATED.

Regarding allegation: Facility staff did not safeguard resident’s personal belongings. It is alleged R1’s clothes have gone missing. Interviews conducted with residents revealed 3 out of 7 residents stated to take care of their personal care themselves. However, personal items have not gone missing. 1 out of 7 residents stated none of their personal belongings have gone missing. 3 out of 7 residents were unable to answer due to cognitive skills. Document review revealed R1’s personal property and valuables dated: 3/8/24 list clothing in general. However, there is not a specific number of items. During facility’s tour LPA observed R1’s room and observed R1’s clothing folded in one closet and personal belongings on another closet.

Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is UNSUBSTANTIATED.

Exit interview was conducted with Adriane Rugen Administrator and a copy of this report was provided.

NAME OF LICENSING PROGRAM MANAGER: Wei Siew Ho
NAME OF LICENSING PROGRAM ANALYST: Mary G Flores
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 05/20/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/20/2025

LIC9099 (FAS) - (06/04)

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