342701121-8-22-2025-27-AS-CACL-DLN2CU-20250918171718

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 342701121
Report Date: 08/22/2025
Date Signed: 08/22/2025 02:18:18 PM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

This is an official report of an unannounced visit/investigation of a complaint received in our office on
07/28/2025 and conducted by Evaluator Pang Lee

PUBLIC

COMPLAINT CONTROL NUMBER: 27-AS-20250728104736

FACILITY NAME:	OAKMONT OF EAST SACRAMENTO		FACILITY NUMBER:	342701121
ADMINISTRATOR:	KATHLEEN GILBEY		FACILITY TYPE:	740
ADDRESS:	5301 F STREET		TELEPHONE:	(916) 905-2400
CITY:	EAST SACRAMENTO	STATE: CA	ZIP CODE:	95819
CAPACITY:	214	CENSUS: 150	DATE:	08/22/2025
		UNANNOUNCED	TIME BEGAN:	01:55 PM
MET WITH:	Kathleen Gilbey		TIME COMPLETED:	02:38 PM

ALLEGATION(S):

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Staff do not ensure residents’ incontinent care needs are being met
Staff do not allow residents to eat their meals in a comfortable manner
Staff do not ensure residents are treated with dignity and respect regarding their health conditions

INVESTIGATION FINDINGS:

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On 08/22/025, Licensing Program Analyst (LPA) Pang Lee arrived unannounced to this facility to conduct a complaint visit. LPA met with Executive Director/Administrator Kathleen Gilbey and explained the purpose of the visit. The purpose of this visit is to deliver complaint findings for the above allegations. The current census is 150.

It was alleged that staff do not ensure residents incontinent care needs are being met. The investigation included interviews with staff, residents, responsible parties, and direct observations. LPA Lee interviewed all 5 facility staff members, all of whom denied that residents’ incontinence care needs are not being met. According to staff interviews, residents are checked, changed, and encouraged to use the toilet every two hours.

CONTINUED LIC 9099-C

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Czarrina A Camilon-Lee
LICENSING EVALUATOR NAME: Pang Lee
LICENSING EVALUATOR SIGNATURE:	DATE: 08/22/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/22/2025

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 3

Control Number 27-AS-20250728104736

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: OAKMONT OF EAST SACRAMENTO	FACILITY NUMBER: 342701121
	VISIT DATE: 08/22/2025

NARRATIVE

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Additionally, LPA Lee interviewed 6 out of 6 family members and friends of residents. None expressed concerns regarding incontinence care, and all reported that their loved ones are regularly changed by care staff. They also stated that they have not observed their loved ones in soiled or unclean incontinence briefs. Interviews were also conducted with 5 out of 5 residents, all of whom stated that their incontinence care needs are being met by the facility staff and expressed no concerns. During a facility observation on 07/30/2025, no signs of incontinence odor were detected. Based on interviews and statements conducted during the investigation process as well as direct observations, LPA Lee was unable to corroborate the allegation that staff do not ensure residents incontinent care are being met.

It was alleged that staff do not allow residents to eat their meals in a comfortable manner. The investigation included interviews with staff, residents, responsible parties, and direct observations. LPA Lee interviewed all five facility staff members. Each staff member denied the allegation and reported that lunch is typically served between 11:30 AM and 1:00 PM. LPA Lee also interviewed six out of six family members and friends of residents. None of them expressed concerns about residents being unable to eat their meals comfortably. They reported regularly sitting with their loved ones during mealtimes and stated that meals are not rushed. They felt residents are given sufficient time to eat and shared that facility staff are often seen sitting with and assisting residents who may need more assistance with feeding. Additionally, interviews were conducted with all five out of five residents. All residents reported no concerns regarding mealtimes. On 7/30/2025, at approximately 11:15 AM, LPA Lee conducted a tour of the memory care unit. During this observation, care staff were seen assisting residents in the dining area. Lunch service began at around 11:20 AM and continued until approximately 1:00 PM. Throughout the observation, LPA Lee observed a calm and unhurried dining environment, where residents were given adequate time to eat. Five care staff were observed assisting residents with their meals, while two med-techs distributed medications. Approximately 29 residents were present in the dining room during this time. Resident 1 (R1) was observed receiving assistance with their meal but later declined further help from staff. Based on interviews and statements conducted during the investigation process as well as direct observations, LPA Lee was unable to corroborate the allegation that staff do not allow residents to eat their meals in a comfortable manner.
It was alleged that staff do not ensure residents are treated with dignity and respect regarding their health conditions.

CONTINUED LIC 9099-C

SUPERVISORS NAME: Czarrina A Camilon-Lee
LICENSING EVALUATOR NAME: Pang Lee
LICENSING EVALUATOR SIGNATURE:	DATE: 08/22/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/22/2025

LIC9099 (FAS) - (06/04)

Page: 2 of 3

Control Number 27-AS-20250728104736

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: OAKMONT OF EAST SACRAMENTO	FACILITY NUMBER: 342701121
	VISIT DATE: 08/22/2025

NARRATIVE

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The investigation included interviews with facility staff, residents, responsible parties, and direct observations. LPA Lee interviewed all five facility staff members. Each staff member denied the allegation, stating that residents are treated with dignity and respect. LPA Lee also interviewed six out of six family members and friends of residents. None expressed concerns about how staff treat residents. One friend of a resident stated, “They are loved here.” Another shared that they have no concerns about the care their loved one receives. A third individual noted they have visited their loved ones’ room and observed staff providing care in a kind and respectful manner. All family members and friends of residents stated that they have not witnessed any incidents of staff treating residents without dignity or respect, especially regarding residents’ health conditions. Additionally, five out of five residents interviewed reported no concerns about how they are treated by staff in relation to their health conditions. Based on interviews and statements conducted during the investigation process as well as direct observations, LPA Lee was unable to corroborate the allegation that staff do not allow residents to eat their meals in a comfortable manner.

The investigation revealed the preponderance of evidence standards have not been met; therefore, the above allegations are found to be UNSUBSTANTIATED. A finding that the complaint allegations are UNSUBSTANTIATED means that although the allegations may have happened or are valid, there is not a preponderance of the evidence to prove that the alleged violation(s)occurred.

Per California Code of Regulations (CCRs) - Title 22, Division 6, Chapter 6, no deficiencies were cited.
A copy of this report was provided at the end of the visit.

SUPERVISORS NAME: Czarrina A Camilon-Lee
LICENSING EVALUATOR NAME: Pang Lee
LICENSING EVALUATOR SIGNATURE:	DATE: 08/22/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/22/2025

LIC9099 (FAS) - (06/04)

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