Inspection Report Summary
Most inspections found no deficiencies, including the most recent annual inspection on October 2, 2025, which was clean and showed compliance with safety, environment, food service, and residents’ rights standards. However, several complaint investigations between late 2024 and mid-2025 substantiated injuries to a resident caused by improper use of a Hoyer Lift, linked to inadequate staff training, resulting in immediate civil penalties of $500 with enhanced penalties pending. Other substantiated issues included a medication administration error in late 2023 and a failure to provide proper eviction notice in mid-2023, while many other complaints were unsubstantiated. The facility appears to have addressed some concerns, as the latest inspection was free of deficiencies after a period with multiple findings related mainly to resident care and staff training. No license suspensions or fines beyond those civil penalties were listed in the available reports.
Deficiencies per Year
4
3
2
1
0
High
Moderate
Unclassified
Census Over Time
Census
Capacity
Inspection Report
Annual Inspection
Census: 67
Capacity: 97
Deficiencies: 0
Oct 2, 2025
Visit Reason
The inspection was a required unannounced annual inspection to evaluate compliance with licensing requirements and facility standards.
Findings
No deficiencies were cited during the inspection. The facility met all safety, environmental, food service, and residents' rights requirements as observed by the Licensing Program Analyst.
Report Facts
Hospice residents: 8
Rooms inspected: 6
Water temperature range: 105
Water temperature range: 120
Freezer temperature: 0
Refrigerator maximum temperature: 40
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Adriane Runge | Administrator | Met with Licensing Program Analyst during inspection and exit interview |
| Kimberly Ramirez | Licensing Program Analyst | Conducted the annual inspection |
| Gina Alvarez | Business Office Director | Met with Licensing Program Analyst to discuss purpose of visit |
| Fernando Fierros | Supervisor | Supervisor overseeing the licensing evaluation |
Inspection Report
Complaint Investigation
Census: 68
Capacity: 97
Deficiencies: 1
Sep 3, 2025
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by an allegation that facility staff caused injuries to a resident during a transfer.
Findings
The investigation substantiated the allegation that Resident #1 sustained injuries to their head during a transfer using a Hoyer Lift assisted by staff. Interviews with staff and residents, record reviews, and observations confirmed the incident and deficiencies in staff training on the Hoyer Lift. Immediate civil penalties were issued due to staff-caused serious injury.
Complaint Details
The complaint alleged that facility staff caused injuries to a resident during a transfer. The allegation was substantiated based on interviews with staff and residents, review of incident reports, and observations. Immediate civil penalties of $500 were issued, with an enhanced civil penalty determination pending.
Severity Breakdown
Type A: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to accord safe, healthful and comfortable accommodations, furnishings and equipment as evidenced by Resident #1 sustaining head injuries during staff-assisted transfer using a Hoyer Lift. | Type A |
Report Facts
Civil penalty amount: 500
Capacity: 97
Census: 68
In-service training dates: Two in-service trainings held on 11/27/2024 and 12/4/2024; additional trainings scheduled for 12/20/2024 and 1/17/2025.
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Tena Herrera | Licensing Program Analyst | Conducted the complaint investigation and authored the report. |
| David Sicairos | Licensing Program Manager | Named in the report as Licensing Program Manager overseeing the investigation. |
| Adriane Runge | Executive Director | Facility administrator met during the investigation and recipient of report and civil penalty notification. |
Inspection Report
Complaint Investigation
Census: 68
Capacity: 97
Deficiencies: 1
Aug 28, 2025
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by an allegation that facility staff caused injuries to a resident during a transfer using a Hoyer Lift.
Findings
The investigation substantiated the allegation that Resident #1 sustained injuries to their head during a transfer with a Hoyer Lift due to staff error. Interviews with staff and residents, record reviews, and observations confirmed the incident and lack of prior training documentation. Immediate civil penalties were issued.
Complaint Details
The complaint alleged that facility staff caused injuries to a resident during a transfer. The allegation was substantiated based on interviews with staff and residents, observations, and record reviews. Immediate civil penalties of $500 were issued due to staff causing serious injury to the resident. An Enhanced Civil Penalty determination is pending.
Severity Breakdown
Type A: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to accord safe, healthful and comfortable accommodations, furnishings and equipment as evidenced by Resident #1 sustaining injuries to their head during staff assistance with a transfer using a Hoyer Lift. | Type A |
Report Facts
Capacity: 97
Census: 68
Civil Penalty Amount: 500
In-service Training Dates: Two in-service training sessions held on 11/27/2024 and 12/4/2024
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Tena Herrera | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| David Sicairos | Licensing Program Manager | Named as Licensing Program Manager overseeing the investigation |
| Adriane Runge | Executive Director | Facility representative met during the investigation and exit interview |
| S1 | Staff who explained lack of prior training documentation and participated in interviews | |
| S2 | Staff involved in the transfer incident causing injury to Resident #1 | |
| S3 | Staff involved in the transfer incident causing injury to Resident #1 | |
| S6 | Staff who had not received training for the Hoyer Lift but used it to assist residents |
Inspection Report
Complaint Investigation
Census: 70
Capacity: 97
Deficiencies: 1
Aug 8, 2025
Visit Reason
The visit was conducted as a Case Management visit during the course of a complaint investigation (#28-AS-20241113164508) related to staff training on operating a hoyer lift, which resulted in injuries to a resident.
Findings
The investigation found that the administrator at the time did not ensure staff were properly trained on how to operate a hoyer lift, with no training records observed in staff files. A deficiency for lack of training was issued.
Complaint Details
Complaint #28-AS-20241113164508 involved injuries to a resident due to improper use of a hoyer lift and lack of staff training. The deficiency for lack of training was not addressed in a prior complaint investigation dated 12/18/2024 but is now being issued.
Severity Breakdown
Type B: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to recruit, employ, and train qualified staff on proper use of a hoyer lift, resulting in injuries to a resident. | Type B |
Report Facts
Census: 70
Total Capacity: 97
Plan of Correction Due Date: Aug 15, 2025
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Angela Boyd | Health Services Director | Met with Licensing Program Analyst during inspection |
| Tena Herrera | Licensing Program Analyst | Conducted the Case Management visit and issued the deficiency |
| David Sicairos | Licensing Program Manager | Named as Licensing Program Manager on report |
Inspection Report
Complaint Investigation
Census: 74
Capacity: 97
Deficiencies: 0
Aug 1, 2025
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by allegations received on 2025-05-12 regarding medication security, falsification of medication records, inadequate supervision during medication administration, and residents being left in soiled diapers for extended periods.
Findings
The investigation found no corroborating evidence to support the allegations. Staff interviews and resident statements confirmed that medications were securely stored, medication records were accurate, adequate supervision was provided during medication administration, and residents were not left in soiled diapers for extended periods. The allegations were determined to be unsubstantiated due to lack of preponderance of evidence.
Complaint Details
The complaint included allegations that staff did not ensure centrally stored medication was locked and inaccessible, falsified medication records, failed to provide adequate supervision resulting in missed medication doses, and left residents in soiled diapers for extended periods. The investigation concluded these allegations were unsubstantiated.
Report Facts
Facility capacity: 97
Census: 74
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Elizabeth Irra | Licensing Program Analyst | Conducted the complaint investigation visit |
| Adriane Runge | Executive Director | Facility administrator and participant in exit interview |
| Gina Alvarez | Business Office Director | Met with Licensing Program Analyst during investigation |
| Angela Boyd | Health Services Director | Arrived during investigation visit and participated |
Inspection Report
Complaint Investigation
Census: 74
Capacity: 97
Deficiencies: 1
Aug 1, 2025
Visit Reason
The visit was a Case Management inspection conducted during a complaint investigation regarding allegations that staff falsified medication records for a resident.
Findings
The investigation found that staff member S-1 falsified medication administration records by documenting administration of Metamucil to resident R-1 on 05/03/25 when the medication was not provided. S-1 was terminated and had previously received disciplinary action for medication documentation errors.
Complaint Details
The complaint alleged staff falsified medication records for another resident pertaining to Oxycodone. During investigation, falsification of medication records for Metamucil for resident R-1 by staff S-1 was discovered and substantiated.
Severity Breakdown
Type A: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to provide Metamucil to resident R-1 on 05/03/25 while documenting it as administered, violating medication administration policies. | Type A |
Report Facts
Capacity: 97
Census: 74
Plan of Correction Due Date: Aug 2, 2025
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Adriane Runge | Executive Director | Met during inspection and received exit interview and report |
| Elizabeth Irra | Licensing Program Analyst | Conducted the Case Management visit and complaint investigation |
| Wei Siew Ho | Licensing Program Manager | Named in licensing program management and signature |
Inspection Report
Complaint Investigation
Census: 69
Capacity: 97
Deficiencies: 0
May 20, 2025
Visit Reason
An unannounced complaint investigation visit was conducted in response to allegations received on 2025-05-14 regarding medication dispensing, resident handling, food service sanitation, and safeguarding of personal belongings at the facility.
Findings
The investigation found no preponderance of evidence to substantiate any of the allegations, including improper medication dispensing, rough handling or yelling at residents, improper food service sanitation practices, and failure to safeguard residents' personal belongings. Staff interviews, resident interviews, document reviews, and observations supported that the facility was providing care as prescribed and maintaining proper practices.
Complaint Details
The complaint investigation was unsubstantiated. Allegations included medication not dispensed as prescribed, rough handling and yelling at residents, improper food service sanitation, and failure to safeguard personal belongings. Interviews and document reviews did not support these allegations, and the facility addressed concerns appropriately.
Report Facts
Residents interviewed: 7
Staff interviewed: 7
Residents medication reviewed: 4
Medication clarification orders: 2
Training dates: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Mary G Flores | Licensing Program Analyst | Conducted the complaint investigation visit |
| Adriane Runge | Executive Director | Facility administrator met during investigation and exit interview |
| Wei Siew Ho | Licensing Program Manager | Named as Licensing Program Manager on report |
Inspection Report
Complaint Investigation
Census: 72
Capacity: 97
Deficiencies: 2
Dec 18, 2024
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by an allegation that facility staff caused injuries to a resident during a transfer.
Findings
The investigation substantiated the allegation that staff caused injuries to Resident #1 during a transfer using a Hoyer Lift. Interviews with staff and residents, record reviews, and observations confirmed the incident and revealed training deficiencies related to the use of the Hoyer Lift. Immediate civil penalties were issued.
Complaint Details
The complaint was substantiated. The allegation was that facility staff caused injuries to a resident during a transfer. Staff interviews confirmed the incident, and the resident sustained a head injury. Immediate civil penalties of $500 were issued, with an enhanced civil penalty determination pending.
Deficiencies (2)
| Description |
|---|
| Failure to ensure all staff who provide assistance with transfers were trained in proper usage of the Hoyer Lift. |
| Resident #1 sustained injuries to their head during staff assistance with a transfer using a Hoyer Lift, including a head laceration and a large scalp hematoma. |
Report Facts
Capacity: 97
Census: 72
Civil Penalty Amount: 500
In-service training dates: Two in-service trainings held on 2024-11-27 and 2024-12-04 after the incident
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Tena Herrera | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| David Sicairos | Licensing Program Manager | Named as Licensing Program Manager overseeing the investigation |
| Adriane Runge | Executive Director | Facility representative met during the investigation and named in the report |
| S1 | Staff who explained lack of prior training documentation for Hoyer Lift | |
| S2 | Staff involved in the transfer incident causing injury to Resident #1 | |
| S3 | Staff involved in the transfer incident causing injury to Resident #1 | |
| S4 | Staff who demonstrated the use of each Hoyer Lift during the investigation | |
| S6 | Staff who had not received training for the Hoyer Lift but used it to assist residents |
Inspection Report
Annual Inspection
Census: 72
Capacity: 97
Deficiencies: 0
Sep 26, 2024
Visit Reason
The inspection was an unannounced required annual inspection visit to evaluate the facility's compliance with regulatory requirements.
Findings
The facility was found to be adhering to operational, staffing, infection control, and safety requirements. The physical plant and environment were inspected with no deficiencies noted. Resident records, personnel training, food service, and disaster preparedness were reviewed and found compliant.
Report Facts
Licensed capacity: 97
Current census: 72
Fire extinguisher last service date: Mar 27, 2024
Emergency drill date: Aug 29, 2024
Hot water temperature range: 106.5 to 110.0
Food supplies: 2
Food supplies: 7
Resident files reviewed: 7
Staff files reviewed: 5
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Elizabeth Irra | Licensing Program Analyst | Conducted the annual inspection visit |
| Adriane Runge | Facility representative met during inspection and received report | |
| Tony Vasallo | Supervisor | Supervisor overseeing the inspection |
| Janette Hill | Administrator/Director | Facility Administrator/Director |
Inspection Report
Complaint Investigation
Census: 72
Capacity: 97
Deficiencies: 0
Jul 30, 2024
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by allegations received on 2024-04-03 regarding staff not preventing a resident from falling and leaving a resident on the floor for an extended period after a fall.
Findings
The investigation found that resident #1 experienced two falls resulting in minor injuries and hospitalization. Staff and residents stated that residents are checked frequently and assessed after falls. There was insufficient evidence to substantiate the allegations, and the complaint was determined to be unsubstantiated.
Complaint Details
The complaint involved allegations that staff did not prevent a resident from falling on multiple occasions and left the resident on the floor for an extended period after falling. The investigation included interviews with staff, residents, and review of hospital documents. The allegations were found unsubstantiated due to lack of preponderance of evidence.
Report Facts
Capacity: 97
Census: 72
Hospitalization duration: 5
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Angelica Rea | Licensing Program Analyst | Conducted the complaint investigation and issued the report |
| Janette Hill | Administrator | Named in investigation interviews |
| Adriane Runge | Executive Director | Met with Licensing Program Analyst during the investigation |
| Lisa Hicks | Licensing Program Manager | Named as Licensing Program Manager on the report |
Inspection Report
Complaint Investigation
Capacity: 97
Deficiencies: 0
Feb 12, 2024
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by allegations received on 09/22/2022 concerning resident safety, supervision, feeding, hydration, and sensor alert device functionality at Oakmont of Whittier facility.
Findings
The investigation included interviews with staff, residents, and review of records. All allegations were found to be unsubstantiated due to lack of preponderance of evidence, with staff and residents confirming adequate care, supervision, feeding, hydration, and functioning sensor alert devices.
Complaint Details
The complaint involved multiple allegations including unwitnessed falls, unsafe environment, inadequate assistance and supervision, inadequate feeding and hydration, and malfunctioning sensor alert devices. The investigation found no substantiation for these allegations.
Report Facts
Facility capacity: 97
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Angelica Rea | Licensing Program Analyst | Conducted the complaint investigation and final visit |
| Lisa Hicks | Licensing Program Manager | Oversaw the complaint investigation |
| Robert Jakini | Administrator | Facility administrator interviewed during investigation |
| Janette Hill | Met with Licensing Program Analyst during final visit |
Inspection Report
Complaint Investigation
Census: 70
Capacity: 97
Deficiencies: 1
Nov 21, 2023
Visit Reason
The inspection visit was conducted in response to a complaint alleging that facility staff did not dispense medications to a resident as prescribed.
Findings
The investigation found that resident #1's medication list was not updated upon return from the hospital, resulting in the resident being administered medications that should have been discontinued. The allegation was substantiated and deficiencies were cited according to California regulations.
Complaint Details
The complaint was substantiated based on review of medication lists, hospital discharge documents, special incident reports, and interviews with facility staff. The facility acknowledged the error and has taken corrective actions including discontinuing the medications and planning medication error prevention training.
Severity Breakdown
Type A: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to administer medications according to physician's directions; resident #1 was still being administered Losartan Potassium 25 mg and Melatonin 3 mg, which should have been discontinued upon hospital discharge. | Type A |
Report Facts
Capacity: 97
Census: 70
Deficiency Type: 1
Plan of Correction Due Date: Dec 21, 2023
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Angelica Rea | Licensing Program Analyst | Conducted the complaint investigation visit |
| Janette Hill | Facility representative met during the visit and exit interview | |
| Leslie Lopez | Health Services Director | Interviewed during the investigation regarding medication administration |
| Lisa Hicks | Licensing Program Manager | Named in report as Licensing Program Manager |
Inspection Report
Annual Inspection
Census: 71
Capacity: 97
Deficiencies: 0
Oct 27, 2023
Visit Reason
An unannounced annual inspection visit was conducted to evaluate the facility's compliance with regulatory requirements.
Findings
The inspection found no deficiencies. The facility was toured, medications and files reviewed, food supply inspected, and staff and residents interviewed. Safety features and cleanliness were verified, and an earthquake/fire drill was confirmed to have been conducted.
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Angelica Rea | Licensing Program Analyst | Conducted the inspection and authored the report. |
| Janette Hill | Executive Director | Met with the Licensing Program Analyst during the inspection and received the report. |
Inspection Report
Complaint Investigation
Census: 68
Capacity: 97
Deficiencies: 1
Jul 25, 2023
Visit Reason
The inspection was conducted as an unannounced complaint investigation in response to an allegation that staff unlawfully evicted a resident while in care.
Findings
The investigation found that resident #1 was not given the required 30 days written eviction notice due to a change in the resident's condition making it difficult to meet their needs. The allegation was substantiated and deficiencies were cited according to California Code of Regulations, Title 22 and Health and Safety Code.
Complaint Details
The complaint alleged that staff unlawfully evicted a resident while in care. The allegation was substantiated based on review of resident records and interviews with family and facility staff.
Severity Breakdown
Type B: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to provide 30 days written eviction notice to resident #1 as required by eviction procedures. | Type B |
Report Facts
Capacity: 97
Census: 68
Deficiency count: 1
Plan of Correction Due Date: Aug 1, 2023
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Angelica Rea | Licensing Program Analyst | Conducted the complaint investigation |
| Janette Hill | Administrator met during investigation and exit interview | |
| Leslie Lopez | Health Services Director | Interviewed during investigation regarding resident care |
| Lisa Hicks | Licensing Program Manager | Named in report as Licensing Program Manager |
Inspection Report
Annual Inspection
Census: 75
Capacity: 97
Deficiencies: 0
Nov 18, 2022
Visit Reason
The inspection was an unannounced annual visit conducted using the Infection Control Evaluation Tool to evaluate compliance with regulations.
Findings
The facility was toured including common areas and resident rooms. No deficiencies were observed. Safety features, infection control measures, medication storage, and food supplies were all found to be in compliance with regulations.
Report Facts
Water temperature range: 108.5
Water temperature range: 116.5
Resident medications reviewed: 7
Food supply duration: 2
Food supply duration: 7
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Angelica Rea | Licensing Program Analyst | Conducted the inspection and met with Executive Director |
| Janette Hill | Executive Director | Met with Licensing Program Analyst during the inspection |
Inspection Report
Complaint Investigation
Census: 75
Capacity: 97
Deficiencies: 0
Nov 18, 2022
Visit Reason
The inspection was conducted in response to a complaint alleging that facility staff were not providing assistance to a resident according to the resident's care plan and that a resident was being illegally evicted.
Findings
The investigation found that staff and administrator denied the allegation of not providing assistance according to the care plan, and residents corroborated that assistance was provided as needed. Regarding the eviction allegation, the facility found a hidden audio and video recording device in the resident's room, which violated the admission agreement, leading to an eviction notice. The allegations were unsubstantiated due to lack of preponderance of evidence.
Complaint Details
The complaint investigation was unsubstantiated. Allegations included failure to provide care per resident's care plan and illegal eviction. The investigation included interviews, file reviews, and photographic evidence. No deficiencies were cited under California Code of Regulations Title 22.
Report Facts
Facility capacity: 97
Census: 75
Eviction notice date: Sep 14, 2022
Complaint received date: Sep 19, 2022
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Angelica Rea | Licensing Program Analyst | Conducted the complaint investigation |
| Janette Hill | Facility representative who assisted with the visit and received the report | |
| Lisa Hicks | Licensing Program Manager | Oversaw the complaint investigation |
Inspection Report
Original Licensing
Census: 68
Capacity: 97
Deficiencies: 0
Aug 30, 2021
Visit Reason
The visit was conducted as a pre-licensing facility evaluation to check the water temperature and to conduct the Component III orientation.
Findings
The water temperature was observed to be between 105°F and 120°F during the visit. The Component III orientation was completed and the visit was documented for licensing purposes.
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Angelica Rea | Licensing Program Analyst | Conducted the pre-licensing facility evaluation visit and observed water temperature. |
| Patricia Gustin | Associate Executive Director | Assisted with the pre-licensing facility evaluation visit. |
Inspection Report
Original Licensing
Census: 68
Capacity: 97
Deficiencies: 0
Aug 24, 2021
Visit Reason
An announced pre-licensing visit was conducted for Oakmont of Whittier following a Change of Ownership application submitted to the Community Care Licensing Division for a Residential Care Facility for the Elderly.
Findings
The facility was toured and inspected, including resident rooms, safety systems, kitchen, and emergency equipment. Several items were noted that must be corrected with proof of correction due by 08/30/2021. The facility was found to have adequate food supply, functioning safety systems, and appropriate resident accommodations.
Report Facts
Residents in assisted living: 41
Residents in memory care: 27
Units in facility: 74
Water temperature range: 120.2
Water temperature range: 125.6
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Angelica Rea | Licensing Program Analyst | Conducted the announced pre-licensing visit and evaluation |
| Patricia Gustin | Associate Executive Director | Facility representative who assisted with the tour and received the report |
| Lisa Hicks | Supervisor | Supervisor overseeing the licensing evaluation |
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