Inspection Report Summary
Most inspections found no deficiencies, including the most recent report on October 31, 2025, which had no citations despite investigating a serious complaint involving a staff member allegedly slapping a resident. Earlier reports from late 2024 showed several substantiated deficiencies related mainly to malfunctioning call pendant systems causing delayed staff response and medication management issues, including failure to administer oxygen and secure medications properly. The facility addressed staff misconduct promptly in isolated incidents, with involved employees suspended or terminated and additional training provided. Several complaint investigations over time were unsubstantiated, indicating many concerns were not confirmed. Overall, the facility’s record shows improvement with recent inspections free of deficiencies after addressing prior issues in resident care, safety equipment, and medication management.
Deficiencies per Year
4
3
2
1
0
Moderate
Unclassified
Census Over Time
Census
Capacity
Inspection Report
Complaint Investigation
Census: 95
Capacity: 121
Deficiencies: 0
Oct 31, 2025
Visit Reason
The visit was an unannounced Case Management inspection conducted in response to an Unusual Incident Report received on 10/29/2025 involving a night shift staff member allegedly slapping a resident during care.
Findings
The investigation found inconsistent accounts of the incident, with the staff member placed on leave pending further notice. No citations were issued during the visit, and the facility plans to conduct new Mandated Reporter training to prevent future occurrences.
Complaint Details
The complaint involved an incident where a night shift staff member slapped a resident. A police report was filed, and the staff member was put on leave due to the nature of the allegations and inconsistent statements.
Report Facts
Police report number: 2511309
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| San Sor | Executive Director | Met with Licensing Program Analysts to discuss the incident and corrective actions |
| Andrew Christy | Licensing Program Analyst | Conducted the inspection visit |
| Grace Luk | Licensing Program Analyst | Conducted the inspection visit |
Inspection Report
Annual Inspection
Census: 95
Capacity: 121
Deficiencies: 0
Aug 8, 2025
Visit Reason
The inspection was an unannounced Required 1 Year Annual inspection conducted by Licensing Program Analysts to evaluate compliance with licensing requirements.
Findings
The facility was found to be in full compliance with no deficiencies noted. All areas toured were adequate, staff and resident files were complete and up to date, medications were properly managed, and safety equipment and emergency plans were current.
Report Facts
Residents present: 95
Total capacity: 121
Hot water temperature readings: 109.8
Hot water temperature readings: 112.8
Hot water temperature readings: 107
Hallway temperature: 75
Fire extinguisher last service date: Jul 4, 2025
Emergency Disaster Plan last update: Jul 29, 2025
Fire drill last conducted: May 27, 2025
Staff files reviewed: 5
Resident files reviewed: 5
Medication Administration Records (MARs) reviewed: 5
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Kim Sor | Executive Director | Met with Licensing Program Analysts during inspection |
| Andrew Christy | Licensing Program Analyst | Conducted the inspection |
| Yasamin Brown | Licensing Program Analyst | Conducted the inspection |
| Harpreet Humpal | Licensing Program Manager | Named as Licensing Program Manager on report |
Inspection Report
Complaint Investigation
Census: 93
Capacity: 121
Deficiencies: 0
Apr 11, 2025
Visit Reason
An unannounced complaint investigation visit was conducted due to an allegation that staff did not follow communicable infection protocols.
Findings
The investigation found that one resident had a norovirus diagnosis but was hospitalized during the infectious period. The facility implemented enhanced cleaning protocols upon the resident's return and monitored other residents and staff, with no other confirmed cases. The allegations were unsubstantiated due to lack of preponderance of evidence.
Complaint Details
The complaint alleged that staff did not follow communicable infection protocols. The investigation concluded the allegations were unsubstantiated.
Report Facts
Complaint Control Number: 15
Complaint Control Number Full: 15-AS-20250408105523
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jill Clancy-Czuleger | Licensing Program Analyst | Conducted the complaint investigation visit |
| Kim Sor | Executive Director | Met with during the investigation |
Inspection Report
Complaint Investigation
Census: 93
Capacity: 121
Deficiencies: 0
Mar 19, 2025
Visit Reason
The visit was an unannounced complaint investigation triggered by a complaint received on 2025-01-15 alleging staff engaged in inappropriate behavior resulting in a resident sustaining an injury.
Findings
The investigation found that the resident's fall was not due to staff inappropriate behavior. Interviews and records indicated the resident was agitated and a fall risk. There was insufficient evidence to substantiate the allegation, and the complaint was determined to be unsubstantiated.
Complaint Details
The complaint alleged staff engaged in inappropriate behavior causing resident injury. The investigation included interviews with multiple staff and review of documents. The allegation was unsubstantiated due to lack of preponderance of evidence.
Report Facts
Complaint Control Number: 15-AS-20250115085215
Capacity: 121
Census: 93
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Kim Sor | Executive Director | Met with Licensing Program Analyst during investigation |
| Lisha Holmes | Licensing Program Analyst | Conducted the complaint investigation |
| Yvonne Flores-Larios | Licensing Program Manager | Named in report as Licensing Program Manager |
Inspection Report
Complaint Investigation
Census: 93
Capacity: 121
Deficiencies: 0
Mar 19, 2025
Visit Reason
The visit occurred to deliver the finding for complaint #15-AS-20250115085215 dated 01/15/25 and to conduct case management with the facility's Executive Director.
Findings
The Licensing Program Analyst conducted counseling on 01/15/25 regarding Care Provider Job Description, Fall Management Protocol, and Residents Rights - Employee Version. Additional training in Diversity, Equity, and Inclusion (DEI) was recommended for one staff member. No citations were issued.
Complaint Details
Complaint #15-AS-20250115085215 was investigated with interviews of staff members S1, S2, S4, and S5. Counseling and training recommendations were made; no citations were issued.
Report Facts
Complaint number: 15
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Kim Sor | Executive Director | Met with Licensing Program Analyst during the visit |
| Lisha Holmes | Licensing Program Analyst | Conducted the visit and delivered complaint findings |
Inspection Report
Complaint Investigation
Census: 89
Capacity: 121
Deficiencies: 0
Jan 16, 2025
Visit Reason
The visit was an unannounced case management inspection triggered by a complaint (LIC624) regarding an incident on 12/31/2024 where a staff member yelled at a resident in the memory care unit.
Findings
The facility conducted a full investigation, suspended and terminated the involved staff member, and provided training on Elder Abuse Reporting and managing aggressive behavior. The resident was evaluated and found not adversely affected. No deficiencies were cited during the visit.
Complaint Details
The complaint involved a staff member yelling at a resident. The staff member was suspended on 12/31/2024 and terminated on 1/5/2025. The facility investigation confirmed the incident and the staff member was deemed ineligible for rehire.
Report Facts
Capacity: 121
Census: 89
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Kim Sor | Executive Director | Met with Licensing Program Analyst during the visit |
| Kelly Nguyen | Licensing Program Analyst | Conducted the inspection visit |
| Bennett Fong | Licensing Program Manager | Named in the report as Licensing Program Manager |
Inspection Report
Complaint Investigation
Census: 92
Capacity: 121
Deficiencies: 0
Jan 8, 2025
Visit Reason
The visit was an unannounced case management inspection triggered by a complaint (LIC624) regarding an incident on 12/25/24 where a staff member placed tape on a resident's mouth to stop her from talking.
Findings
The investigation confirmed the staff member admitted to the action and was suspended and terminated. The resident was evaluated and appeared not adversely affected. The facility conducted staff training on Resident Rights. No deficiencies were cited during the visit.
Complaint Details
The complaint involved a staff member placing tape on a resident's mouth. The staff member was suspended immediately and later terminated. The resident was evaluated and found not to be adversely affected. The staff member expressed remorse and was deemed ineligible for rehire.
Report Facts
Incident date: Dec 25, 2024
Staff suspension date: Dec 25, 2024
Staff termination date: Dec 31, 2024
Training dates: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Gregory Clark | Licensing Program Analyst | Conducted the case management visit and investigation |
| Kim Sor | Executive Director | Met with Licensing Program Analyst and involved in the investigation |
Inspection Report
Complaint Investigation
Census: 91
Capacity: 121
Deficiencies: 3
Dec 12, 2024
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by allegations received on 2024-12-06 regarding oxygen administration, medication management, and medication accessibility at Oakmont of Concord facility.
Findings
The investigation substantiated three allegations: staff failed to ensure required oxygen administration, mismanaged resident's medication by administering morphine late, and left medication accessible to others. One allegation regarding staff not preventing residents from wandering was found unsubstantiated.
Complaint Details
The complaint investigation was substantiated for allegations that staff did not ensure required oxygen administration, mismanaged medication timing, and left medication accessible to others. The allegation that staff did not prevent residents from wandering was unsubstantiated.
Severity Breakdown
Type B: 3
Deficiencies (3)
| Description | Severity |
|---|---|
| Failure to ensure hospice resident had required oxygen administration as prescribed by hospice care team. | Type B |
| Failure to provide timely medication administration for comfort care. | Type B |
| Failure to safely store a controlled substance medication, leaving it accessible to others. | Type B |
Report Facts
Capacity: 121
Census: 91
Deficiencies cited: 3
Plan of Correction Due Date: Dec 30, 2024
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Kim Sor | Executive Director | Met with Licensing Program Analyst during investigation and named in findings |
| Daisy Panlilio | Licensing Program Analyst | Conducted complaint investigation visit |
| Bennett Fong | Licensing Program Manager | Named as Licensing Program Manager on report |
Inspection Report
Complaint Investigation
Census: 89
Capacity: 121
Deficiencies: 2
Nov 15, 2024
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by allegations that the facility call pendant system was not functioning at all times and that staff did not respond to residents' requests for assistance in a timely manner.
Findings
The investigation substantiated that the call pendant system was malfunctioning from June 2024 to October 2024 and staff response to residents' requests was delayed, posing a potential health and safety risk. Documentation for staff training and notifications regarding the pendant system issues was incomplete or not provided.
Complaint Details
The complaint was substantiated. Allegations included malfunctioning call pendant system and untimely staff response to residents' requests. Interviews with staff and residents confirmed the issues. Documentation for staff training and notifications was insufficient.
Severity Breakdown
Type B: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Failure to ensure the call pendant system was functioning properly at all times and failure to alert staff and residents of malfunctions, resulting in delayed care. | Type B |
| Failure to provide timely care and supervision to residents, posing a potential health and safety risk. | Type B |
Report Facts
Capacity: 121
Census: 89
Deficiencies cited: 2
Plan of Correction Due Date: 7
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Lisha Holmes | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Yvonne Flores-Larios | Licensing Program Manager | Oversaw the complaint investigation |
| Kim S Sor | Executive Director | Facility administrator interviewed during investigation |
| Kashvi Patel | Concierge | Facility representative who signed the report and participated in exit interview |
Inspection Report
Complaint Investigation
Census: 89
Capacity: 121
Deficiencies: 1
Nov 4, 2024
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by a complaint received on 2024-07-05 alleging that staff were not meeting the needs of residents in care.
Findings
The investigation substantiated the allegation that staff were not meeting the needs of residents due to malfunctions and delayed response times of the call pendant system. The facility failed to ensure the call pendants were working properly and did not alert staff and residents during malfunctions, posing a potential health and safety risk.
Complaint Details
The complaint was substantiated. The allegation was that staff were not meeting the needs of residents in care due to issues with the Assisted Living pendant system and Memory Care call button malfunctions and delayed responses.
Severity Breakdown
Type B: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to ensure call pendants were working properly at all times, failure to alert staff and residents of malfunctions, and failure to provide timely care, posing a potential health and safety risk. | Type B |
Report Facts
Capacity: 121
Census: 89
Plan of Correction Due Date: Nov 25, 2024
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Lisha Holmes | Licensing Program Analyst | Conducted the complaint investigation and amended the report |
| Yvonne Flores-Larios | Licensing Program Manager | Named as Licensing Program Manager overseeing the investigation |
| Kim S Sor | Administrator / Executive Director | Facility Administrator interviewed during investigation |
| Kashvi Patel | Concierge | Met with Licensing Program Analyst and signed the report on behalf of the facility |
Inspection Report
Complaint Investigation
Census: 89
Capacity: 121
Deficiencies: 0
Nov 4, 2024
Visit Reason
The inspection was an unannounced complaint investigation visit conducted in response to allegations received on 2024-07-05 regarding staff retaliation against residents and the conduct of resident council meetings without staff presence.
Findings
The investigation included interviews with staff and residents and review of documentation. The allegations that staff retaliated against residents and that resident council meetings were not conducted without staff presence were found to be unsubstantiated based on the information obtained.
Complaint Details
The complaint alleged staff retaliation against residents and that the licensee did not ensure a portion of resident council meetings were conducted without facility staff present. The investigation found no evidence of retaliation or improper conduct of meetings, resulting in the allegations being unsubstantiated.
Report Facts
Capacity: 121
Census: 89
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Lisha Holmes | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Yvonne Flores-Larios | Licensing Program Manager | Oversaw the complaint investigation |
| San Sor | Executive Director | Facility representative interviewed during the investigation |
Inspection Report
Annual Inspection
Census: 89
Capacity: 121
Deficiencies: 0
Aug 23, 2024
Visit Reason
The inspection was an unannounced 1-Year Annual Required inspection conducted to evaluate compliance with licensing requirements.
Findings
The Licensing Program Analysts toured the facility and reviewed resident and staff records, medications, and safety equipment. No deficiencies were cited during the visit.
Report Facts
Residents records reviewed: 6
Staff records reviewed: 6
Fire extinguisher last serviced: Feb 7, 2024
Emergency disaster drill last conducted: Jun 27, 2024
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| San Sor | Executive Director | Met with Licensing Program Analysts during inspection |
| Ardalan Gharachorloo | Licensing Program Analyst | Conducted the inspection |
| David Doidge | Licensing Program Analyst | Conducted the inspection |
Inspection Report
Complaint Investigation
Census: 89
Capacity: 121
Deficiencies: 0
Mar 20, 2024
Visit Reason
An unannounced complaint investigation visit was conducted in response to an allegation that staff were not ensuring that residents' room phones were working properly.
Findings
The investigation found that the facility does not control residents' individual phone lines and staff assist residents with phone issues. The allegation was determined to be unfounded, and no deficiencies were observed or cited during the visit.
Complaint Details
The complaint was investigated and found to be unfounded, meaning the allegation was false or without reasonable basis.
Report Facts
Capacity: 121
Census: 89
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jill Clancy-Czuleger | Licensing Program Analyst | Conducted the complaint investigation |
| Sal Sor | Executive Director | Met with the Licensing Program Analyst during the investigation |
Inspection Report
Annual Inspection
Census: 88
Capacity: 121
Deficiencies: 0
Aug 1, 2023
Visit Reason
The inspection was an unannounced Required 1 Year Annual inspection conducted to evaluate the facility's compliance with licensing regulations.
Findings
The facility was found to be in compliance with no deficiencies cited. The inspection included a tour of the facility, review of resident and staff records, and verification of safety measures such as fire clearance, temperature controls, and medication storage.
Report Facts
Residents records reviewed: 8
Staff records reviewed: 10
Resident medications reviewed: 8
Fire clearance capacity: 113
Fire clearance capacity: 8
Fire extinguisher last service date: Feb 6, 2023
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Rachel Benoza | Resident Care Coordinator | Met with Licensing Program Analyst during inspection |
| San Sor | Executive Director | Met with Licensing Program Analyst during inspection |
| Avon Nguyen | Administrator | Named as facility administrator |
| Paris Watson | Licensing Program Analyst | Conducted the inspection |
| Yvonne Flores-Larios | Licensing Program Manager | Named in report header |
Inspection Report
Complaint Investigation
Census: 87
Capacity: 121
Deficiencies: 0
May 17, 2023
Visit Reason
The visit was an unannounced complaint investigation conducted in response to allegations that the facility did not have proper provisions for residents during a power outage and that staff did not respond to residents' call buttons in a timely manner.
Findings
The investigation found that the facility had procedures for power outages and made accommodations for residents during a recent outage. Staff response times to call buttons varied depending on circumstances but were generally within 15 minutes. There was insufficient evidence to substantiate the allegations, and the complaint was deemed unsubstantiated.
Complaint Details
The complaint was unsubstantiated due to lack of preponderance of evidence to prove the alleged violations did or did not occur.
Report Facts
Capacity: 121
Census: 87
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Avon Nguyen | Executive Director | Met with Licensing Program Analyst during investigation |
| Paris Watson | Licensing Program Analyst | Conducted the complaint investigation |
| Yvonne Flores-Larios | Licensing Program Manager | Named in report as Licensing Program Manager |
Inspection Report
Complaint Investigation
Census: 85
Capacity: 121
Deficiencies: 1
Jan 19, 2023
Visit Reason
The visit was a Case Management inspection conducted in response to complaint number 15-AS-20211020151456 to evaluate compliance with regulations.
Findings
During the inspection, Licensing Program Analysts observed oxygen tanks in a resident's apartment that were not secured to a stand or wall, posing a potential health and safety risk. This deficiency was cited under California Code of Regulations, Title 22.
Complaint Details
The visit was conducted due to complaint #15-AS-20211020151456. The deficiency related to unsecured oxygen tanks was observed and cited.
Deficiencies (1)
| Description |
|---|
| Oxygen tanks in resident R3's apartment were not secured in a stand or to the wall as required. |
Report Facts
Capacity: 121
Census: 85
Deficiency Type Count: 1
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Susana Chavez | Memory Care Director | Met with Licensing Program Analysts during the inspection |
| Lizette Francisco | Licensing Program Analyst | Conducted the inspection and cited deficiencies |
| Harpreet Humpal | Licensing Program Manager | Supervisor overseeing the inspection |
Inspection Report
Complaint Investigation
Census: 85
Capacity: 121
Deficiencies: 0
Jan 19, 2023
Visit Reason
The visit was an unannounced complaint investigation conducted in response to multiple allegations received on 10/20/2021 regarding resident visitation restrictions, unexplained injury, and failure to ensure a resident had glasses.
Findings
The investigation found that family members were allowed to visit residents with scheduled appointments, the resident's missing teeth were due to dental extractions, and the resident's glasses were not always worn by choice. Another allegation about denial of a TV was found to be unfounded. Overall, the allegations were unsubstantiated or unfounded.
Complaint Details
The complaint investigation was unsubstantiated. Allegations included staff not allowing resident to visit with family, resident having an unexplained injury, staff not ensuring resident had glasses, and staff not allowing resident to have a TV. The investigation found no preponderance of evidence to prove violations; the TV allegation was unfounded.
Report Facts
Capacity: 121
Census: 85
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Lizette Francisco | Licensing Program Analyst | Conducted the complaint investigation and delivered findings |
| Susana Chavez | Memory Care Director | Met with investigators during the complaint investigation |
| Harpreet Humpal | Licensing Program Manager | Named as Licensing Program Manager on the report |
Inspection Report
Complaint Investigation
Census: 89
Capacity: 121
Deficiencies: 1
Dec 9, 2022
Visit Reason
The visit was an unannounced case management follow-up on an incident report regarding missing personal property at the facility.
Findings
The facility failed to safeguard a resident's personal property, as confirmed by the resident's report and a police report documenting the loss of towels and bed sheets. A deficiency was cited for this failure.
Complaint Details
The visit was triggered by a complaint regarding missing personal property. The deficiency was substantiated based on resident and police reports.
Severity Breakdown
Type B: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to make reasonable efforts to safeguard resident property, resulting in loss of personal belongings posing a potential health and safety risk. | Type B |
Report Facts
Missing items: 5
Capacity: 121
Census: 89
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Rachel Benosa | Resident Care Coordinator | Met with Licensing Program Analysts during visit |
| Angeles Sticka | Administrator | Facility administrator named in report header |
| Bennett Fong | Licensing Program Manager | Named as Licensing Program Manager and Supervisor |
| Daisy Panlilio | Licensing Program Analyst | Conducted inspection and signed report |
Inspection Report
Annual Inspection
Census: 89
Capacity: 121
Deficiencies: 0
Dec 9, 2022
Visit Reason
The visit was an unannounced annual Infection Control Inspection conducted to evaluate the facility's compliance with infection control standards.
Findings
The inspection found the facility to be in compliance with infection control requirements, including proper PPE use, adequate food supply, posted visitor policies, and maintenance of safety equipment. No deficiencies were cited during the visit.
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Rachel Benoza | Resident Care Coordinator | Met during the inspection and explained the purpose of the visit. |
| Avon Nguyen | Executive Director | Joined the inspection visit and toured the facility with the Licensing Program Analyst. |
| Paris Watson | Licensing Program Analyst | Conducted the annual Infection Control Inspection. |
| Yvonne Flores-Larios | Licensing Program Manager | Named as Licensing Program Manager on the report. |
Inspection Report
Census: 85
Capacity: 121
Deficiencies: 2
May 17, 2022
Visit Reason
Unannounced case management visit conducted due to a COVID-19 outbreak at the facility since 05/03/2022.
Findings
The Licensing Program Analyst observed residents not wearing masks and the administrator failing to follow Community Care Licensing Division (CCLD) reporting requirements related to the COVID-19 outbreak. Deficiencies were cited from the California Code of Regulations.
Severity Breakdown
Type B: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Failure to submit a written report to the licensing agency and responsible person within seven days of occurrence. | Type B |
| Failure to report epidemic outbreaks within 24 hours to the licensing agency and local health officer. | Type B |
Report Facts
Capacity: 121
Census: 85
Plan of Correction Due Date: May 27, 2022
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Julius Osorio | Interim Executive Director | Met with Licensing Program Analyst during the visit |
| Leslie Ibo | Licensing Program Analyst | Conducted the inspection visit and authored the report |
| Harpreet Humpal | Licensing Program Manager | Supervisor overseeing the inspection |
Inspection Report
Original Licensing
Census: 77
Capacity: 121
Deficiencies: 1
Aug 2, 2021
Visit Reason
The visit was an unannounced Pre-Licensing inspection conducted to evaluate the facility for licensure.
Findings
The facility was toured and found to have clean, fully furnished resident rooms, proper safety equipment, and adequate food supply. However, several staff members did not have current first aid training on file, which must be corrected before licensure is recommended.
Deficiencies (1)
| Description |
|---|
| Staff members S1, S2, S4, S6, S7 did not have current first aid training on file. |
Report Facts
Fire clearance capacity: 121
Food supply duration: 7
Food supply duration: 2
Hot water temperature: 112.8
Fire extinguisher last serviced: Feb 11, 2021
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Angeles Sticka | Executive Director | Met with Licensing Program Analyst during inspection |
| Grace Luk | Licensing Program Analyst | Conducted the Pre-Licensing inspection |
| Harpreet Humpal | Licensing Program Manager | Named as Licensing Program Manager on report |
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