336412249-3-20-2026-18-AS-APEZ-DSP38L-20260330180142

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 336412249
Report Date: 03/20/2026
Date Signed: 03/20/2026 11:00:46 AM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
RIVERSIDE ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

This is an official report of an unannounced visit/investigation of a complaint received in our office on
09/07/2022 and conducted by Evaluator Seo Jeon

PUBLIC

COMPLAINT CONTROL NUMBER: 18-AS-20220907152658

FACILITY NAME:	GOLDEN OAK RESIDENTIAL CARE		FACILITY NUMBER:	336412249
ADMINISTRATOR:	ABIGAIL MEJARES		FACILITY TYPE:	740
ADDRESS:	36190 CHITTAM WOOD PLACE		TELEPHONE:	(951) 461-9971
CITY:	MURRIETA	STATE: CA	ZIP CODE:	92562
CAPACITY:	6	CENSUS: 4	DATE:	03/20/2026
		UNANNOUNCED	TIME BEGAN:	09:45 AM
MET WITH:	Cristina Uy, House Manager		TIME COMPLETED:	11:20 AM

ALLEGATION(S):

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Staff did not provide adequate nutrition to resident, resulting in resident’s death
Resident developed a pressure injury due to staff neglect
Staff left resident in urine soaked bedding for extended periods of time
Staff did not provide resident with adequate fluids
Resident sustained an injury due to staff not providing a safe sleep environment

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Seo Jeon conducted an unannounced visit to the facility to deliver findings of the above allegations. LPA met with Cristina Uy, House Manager and informed them of the visit. The Department’s investigation involved interviews with staff and residents and review of records.

On 09-07-2022, Community Care Licensing (The Department) received a complaint report with the following allegations.

It was alleged that staff did not provide adequate nutrition to resident, resulting in resident’s death. Information received indicated that Resident #1 (R1) was not provided with enough food, resulting in loss of weight. LPA’s records review revealed that R1 had resided for only 10 days in June 2022 in the facility. R1 had been under hospice care until R1 passed away in July 2022. LPA’s attempts to contact R1’s relevant party and hospice agency were unsuccessful due to their non-responsiveness. Continued on LIC9099-C...

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Rikesha Stamps
LICENSING EVALUATOR NAME: Seo Jeon
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 18-AS-20220907152658

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
RIVERSIDE ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: GOLDEN OAK RESIDENTIAL CARE	FACILITY NUMBER: 336412249
	VISIT DATE: 03/20/2026

NARRATIVE

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LPA conducted an interview with Staff #1 (S1) who stated that all residents have been provided with three (3) meals a day and plenty of snacks. S1 stated that R1’s records were not available due to expiration of record retention periods. LPA conducted interviews with three (3) residents, all of whom stated that they have had no issues with food services. The Department’s investigation did not provide enough information to corroborate the allegation that staff did not provide adequate nutrition to resident, resulting in resident’s death. This allegation is unsubstantiated.

It was alleged that resident developed a pressure injury due to staff neglect. Information received indicated that R1’s pressure injury became so much worse that wound care personnel advised that there was nothing they could do. LPA’s records review revealed that R1 had pressure injury already before R1 was admitted to the facility. LPA conducted an interview with S1 who stated that all residents receive one (1) to two (2) hour check. S1 stated that R1 arrived at the facility with a bruise on their elbow, but R1 did not have pressure injuries. LPA’s attempts to contact R1’s relevant party and hospice agency were unsuccessful due to their non-responsiveness. The Department’s investigation did not provide enough information to corroborate the allegation that resident developed a pressure injury due to staff neglect. Based on records review and interviews conducted, this allegation is unsubstantiated.

It was alleged that staff left resident in urine soaked bedding for extended periods of time. LPA’s attempt to contact R1’s relevant party was unsuccessful due to their non-responsiveness. LPA conducted an interview with S1 who stated that all residents receive one (1) to two (2) hour check. The Department’s investigation did not provide enough information to corroborate the allegation that staff left resident in urine soaked bedding for extended periods of time. This allegation is unsubstantiated.

It was alleged that staff did not provide resident with adequate fluids. Information received indicated that R1’s hospice nurse informed R1’s relevant party that R1 was severely dehydrated after leaving the facility. LPA’s attempts to contact R1’s relevant party and hospice agency were unsuccessful due to their non-responsiveness. LPA conducted an interview with S1 who stated that all residents have been provided with water and drinks throughout the day. LPA conducted interviews with three (3) residents, all of whom stated that they have had no issues with the facility services. The Department’s investigation did not provide enough information to corroborate the allegation that staff did not provide resident with adequate fluids. This allegation is unsubstantiated.

Continued on LIC9099-C....

SUPERVISORS NAME: Rikesha Stamps
LICENSING EVALUATOR NAME: Seo Jeon
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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Control Number 18-AS-20220907152658

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
RIVERSIDE ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: GOLDEN OAK RESIDENTIAL CARE	FACILITY NUMBER: 336412249
	VISIT DATE: 03/20/2026

NARRATIVE

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It was alleged that resident sustained an injury due to staff not providing a safe sleep environment. Information received indicated that R1 sustained head wound from bed rails. LPA’s attempt to contact R1’s relevant party was unsuccessful due to their non-responsiveness. LPA conducted an interview with S1 who stated that staff have provided pillows to residents who use bed rails to avoid any injuries. LPA conducted interviews with three (3) residents, all of whom denied having any injuries from bed rails. The Department’s investigation did not provide enough information to corroborate the allegation that resident sustained an injury due to staff not providing a safe sleep environment. This allegation is unsubstantiated.

A finding that the complaint is UNSUBSTANTIATED means 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 where a copy of this report was provided.

SUPERVISORS NAME: Rikesha Stamps
LICENSING EVALUATOR NAME: Seo Jeon
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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