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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 374604281
Report Date: 10/16/2025
Date Signed: 10/16/2025 05:50:40 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN DIEGO RO, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108
This is an official report of an unannounced visit/investigation of a complaint received in our office on
06/02/2021 and conducted by Evaluator Dang Nguyen
COMPLAINT CONTROL NUMBER: 08-AS-20210602083905
FACILITY NAME:OAKMONT OF PACIFIC BEACHFACILITY NUMBER:
374604281
ADMINISTRATOR:AMIRHOUSHMAND,SHAWNFACILITY TYPE:
740
ADDRESS:955 GRAND AVETELEPHONE:
(858) 373-9300
CITY:SAN DIEGOSTATE: CAZIP CODE:
92109
CAPACITY:92CENSUS: 73DATE:
10/16/2025
UNANNOUNCEDTIME BEGAN:
05:00 PM
MET WITH:Health Services Director Keisha BeanTIME COMPLETED:
06:00 PM
ALLEGATION(S):
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Facility staff did not meet the needs of a resident with dementia.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Dang Nguyen conducted an unannounced subsequent visit to deliver a finding regarding the above prior complaint allegation. LPA was welcomed by, identified himself to, and discussed the purpose of the visit with Health Services Director Keisha Bean.

The Complainant alleged that facility staff did not meet the needs of resident [Resident #1 (R1)] with dementia. [See LIC 811 Confidential Names List for of select person identifiers used in this report.] CCLD’s investigation involved multiple unannounced facility tours/welfare checks and multiple interviews of relevant managers, frontline staff, and outside sources. The Department also reviewed pertinent administrative files, care records, and E-mail correspondence.

[CONTINUED ON LIC 9099, 1 of 2]
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Simon Jacob
LICENSING EVALUATOR NAME: Dang Nguyen
LICENSING EVALUATOR SIGNATURE:

DATE: 10/16/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/16/2025
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 6
Control Number 08-AS-20210602083905
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN DIEGO RO, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108
FACILITY NAME: OAKMONT OF PACIFIC BEACH
FACILITY NUMBER: 374604281
VISIT DATE: 10/16/2025
NARRATIVE
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[CONTINUED FROM LIC 9099] According to their LIC602 Physician’s Report, R1 was diagnosed with Alzheimer’s Dementia. Their doctor wrote that R1 was able to walk without any motor impairment or assistive device, but due to their cognitive impairment, R1 was not safe to leave the facility unassisted. Interviews of staff and outside sources unanimously showed that R1 resided in the Assisted Living (AL) section of the facility, where there were neither secured perimeter nor delayed-egress doors present. During the allegation period, Licensee employed a Phillips Roam Alert system at the facility, which helped staff monitor residents in AL who were diagnosed with dementia. The system worked by having selected residents wear a Roam Alert Bracelet device. When such residents came near the thresholds of perimeter door exits, the system would trigger an audible localized alarm at that door and send a wireless signal to the pager devices which the caregivers carried, prompting staff to then redirect the resident away from the door. The system did not physically prevent residents from exiting (such doors remained unlocked from the inside).

Licensee’s Phillips Roam Alert system was consistent with CCR 87705, titled Care of Persons with Dementia, which requires Licensees to install “an auditory device or other staff alert feature to monitor exits on exterior doors” that are accessible to residents who “who may be at risk for elopement.” The facility’s written Plan of Operation (on file with CCLD) and Admissions Agreement contract both reiterated that the Roam Alert Bracelet was a safety requirement for any resident diagnosed with dementia living in the facility’s AL section. Licensee’s written Individual Service Plan (i.e., Care Plan) for R1 reiterated that R1 had dementia, was not safe to leave the facility unassisted, and needed to continuously wear their Phillips “Roam Alert Bracelet” for their personal safety. Per manager interviews, Licensee required its caregivers to respond to Roam Alert alarms as quickly as possible, but not longer than five (5) minutes. Staff interviews, corroborated by R1’s Admissions Agreement and an E-mail from a senior manager, also showed that that facility’s exterior exit doors (including the lobby’s front door) were required to be physically locked from the outside at nighttime, for resident safety.

The Complainant claimed that on a day in March 2021, they personally observed that R1’s Roam Alert Bracelet wrist strap had been cut, and the device was sitting atop R1’s bedside table; R1 allegedly told them that they had not worn the bracelet “for a while.” Interviews of two facility managers [Staff #1 (S1) and Staff #2 (S2)] showed that at some point during the allegation period, R1’s Roam Alert Bracelet indeed had been cut off/removed, and that S2 subsequently reattached the device to R1. The totality of interviews did not clearly establish how long the Roam Alert Bracelet had been detached from R1 before discovery/correction (making it difficult to evaluate Licensee fault/culpability). [CONTINUED ON LIC 9099-C, 2 of 2]
SUPERVISORS NAME: Simon Jacob
LICENSING EVALUATOR NAME: Dang Nguyen
LICENSING EVALUATOR SIGNATURE:

DATE: 10/16/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/16/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 6
Control Number 08-AS-20210602083905
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN DIEGO RO, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108
FACILITY NAME: OAKMONT OF PACIFIC BEACH
FACILITY NUMBER: 374604281
VISIT DATE: 10/16/2025
NARRATIVE
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[CONTINUED FROM LIC 812-C, 1 of 2]

The Complainant claimed that on a day in March 2021, and again on a day in May 2021, the facility’s front door was not locked form the outside at nighttime, as required. They also claimed that during the May 2021 date, R1’s Roam Alert Bracelet triggered the lobby front door audible alarm, but it took over twenty-five (25) minutes for the first facility staff to respond to it.

CCLD subsequently obtained video recording, which was filmed around 9:30 PM on 05/02/2021. The video showed: a) The facility’s front door was unlocked during this night, allowing any person to enter from the outside without staff awareness/involvement; and, b) A loud audible alarm continuously sounded at the lobby front door, which facility staff did not respond to during 13-minute video. The person who filmed the video told CCLD that the video ended there because there was no more storage space on their smart phone camera, but that it actually took staff nearly twice as long to respond to this alarm.

Based on records and interviews, a preponderance of evidence exists to show that facility staff did not meet the safety needs of a resident diagnosed with dementia. The allegation is therefore Substantiated, and one (1) deficiency was cited for it per California Code of Regulations, Title 22 (refer to the attached LIC 9099-D page). A Plans of Correction was jointly developed with the Licensee.

An exit interview was conducted with Health Services Director Keisha Bean, to whom a copy of this report, the LIC 9099-D page, and the Licensee/Appeal Rights (LIC9058 03/22) were provided.
SUPERVISORS NAME: Simon Jacob
LICENSING EVALUATOR NAME: Dang Nguyen
LICENSING EVALUATOR SIGNATURE:

DATE: 10/16/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/16/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 6
Citations on this Visit Report are Under Appeal!

Control Number 08-AS-20210602083905
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN DIEGO RO, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108

FACILITY NAME: OAKMONT OF PACIFIC BEACH
FACILITY NUMBER: 374604281
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/16/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Under Appeal
Type B
11/16/2025
Section Cited
CCR
87468.2(a)(4)
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87468.2 Additional Personal Rights of Residents in Privately Operated Facilities: “(a) …residents in privately operated residential care facilities for the elderly shall have all of the following personal rights: (4) To care, supervision, and services that meet their individual needs and are delivered by staff that are sufficient in numbers, qualifications, and competency to meet their needs.” This requirement was not met, as evidenced by:
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Licensee agreed to retrain all current caregivers and receptionists on the following points: a) Roam Alerts represent a close-elopement event, and are thus high priority signals which take precedence over other care tasks, resident call lights, and shift change meetings; b) When a Roam Alert is triggered, staff must continue to search until the resident who that device is tied to confirmed safe; c) List of all current residents who wear Roam Alert devices, and where staff can look for an updated listing of such residents, in real time; d) The importance of timely alerting management if staff observe a Roam Alert bracelet is missing from a designated resident, and e) The importance of double-checking that all facility exterior doors are locked from the outside at night, before the receptionist leaves shift. Licensee agreed to submit the training sign-in sheet to LPA, by the POC due date.
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Based on video, records, and interviews, Licensee did not ensure that 1 of 75 residents (R1) had the care and supervision needed to meet their individual needs. This posed a potential safety risk to persons in care.
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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: Simon Jacob
LICENSING EVALUATOR NAME: Dang Nguyen
LICENSING EVALUATOR SIGNATURE:

DATE: 10/16/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/16/2025
LIC9099 (FAS) - (06/04)
Page: 4 of 6
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN DIEGO RO, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108
This is an official report of an unannounced visit/investigation of a complaint received in our office on
06/02/2021 and conducted by Evaluator Dang Nguyen
COMPLAINT CONTROL NUMBER: 08-AS-20210602083905

FACILITY NAME:OAKMONT OF PACIFIC BEACHFACILITY NUMBER:
374604281
ADMINISTRATOR:AMIRHOUSHMAND,SHAWNFACILITY TYPE:
740
ADDRESS:955 GRAND AVETELEPHONE:
(858) 373-9300
CITY:SAN DIEGOSTATE: CAZIP CODE:
92109
CAPACITY:92CENSUS: 73DATE:
10/16/2025
UNANNOUNCEDTIME BEGAN:
05:00 PM
MET WITH:Health Services Director Keisha BeanTIME COMPLETED:
06:00 PM
ALLEGATION(S):
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Facility's egress alert system is unreliable.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Dang Nguyen conducted an unannounced subsequent visit to deliver a finding regarding the above prior complaint allegation. LPA was welcomed by, identified himself to, and discussed the purpose of the visit with Health Services Director Keisha Bean.

The Complainant alleged that facility's egress alert system was unreliable. CCLD’s investigation involved an unannounced facility tour to test and evaluate of the facility’s Phillips Roam Alert System hardware. The Department also interviewed pertinent staff and reviewed relevant administrative records.

On 06/11/2021, assisted by the facility’s Maintenance Director, LPA performed practical testing of various hardware components of the facility’s Phillips Roam Alert electronic ecosystem. All Roam Alert bracelet chips were found to be operating correctly. The chips were tested using an electronic testing wand designed for this purpose. [CONTINUED ON LIC 9099-C]
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Simon Jacob
LICENSING EVALUATOR NAME: Dang Nguyen
LICENSING EVALUATOR SIGNATURE:

DATE: 10/16/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/16/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 5 of 6
Control Number 08-AS-20210602083905
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN DIEGO RO, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108
FACILITY NAME: OAKMONT OF PACIFIC BEACH
FACILITY NUMBER: 374604281
VISIT DATE: 10/16/2025
NARRATIVE
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[CONTINUED FROM LIC 9099-A]

All chips were also physically carried through multiple exterior exit doors thresholds (to include the lobby front door), for a total of three (3) passes per door. The chips consistently triggered a loudly audible alarm at the door annunciator itself and sent signals to multiple pager devices which the caregivers carried. Both types of alerts continued to be active until staff silenced them by entering a manual key code at the triggering door. This battery of tests, corroborated by interviews of facility managers and frontline caregivers, showed the facility’s egress alert system was reliably working, from a technical/hardware standpoint.

Based on records and interviews, a preponderance of evidence does not exist to show that the facility’s egress alert system was unreliable. The allegation is therefore Unsubstantiated, and no deficiency was cited for it.

An exit interview was conducted with Health Services Director Keisha Bean, to whom a copy of this report and the Licensee/Appeal Rights (LIC9058 03/22) were provided.
SUPERVISORS NAME: Simon Jacob
LICENSING EVALUATOR NAME: Dang Nguyen
LICENSING EVALUATOR SIGNATURE:

DATE: 10/16/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/16/2025
LIC9099 (FAS) - (06/04)
Page: 6 of 6