Inspection Reports for
Pleasant Hill Oasis
40 BOYD RD, PLEASANT HILL, CA, 94523
Back to Facility ProfileDeficiencies (last 5 years)
Deficiencies (over 5 years)
6.8 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
70% worse than California average
California average: 4 deficiencies/yearDeficiencies per year
16
12
8
4
0
Occupancy
Latest occupancy rate
100% occupied
Based on a November 2025 inspection.
Occupancy rate over time
Inspection Report
Census: 49
Capacity: 49
Deficiencies: 3
Date: Nov 18, 2025
Visit Reason
Unannounced Case Management visit to assess deficiencies not cleared from a prior Annual Inspection and Plan of Correction.
Findings
Multiple deficiencies were observed including unlocked medication room door, unattended cleaning chemicals, dirty floors, and unsafe storage of items outside. Repeat violations were noted with civil penalties assessed.
Deficiencies (3)
CCR 87465(h)(2) Centrally stored medications were not kept in a safe and locked place, with the medication room door unlocked and unattended by staff.
CCR 87309(a) Disinfectants and cleaning chemicals including Clorox Bleach were left unattended and accessible to residents.
CCR 87303(a)(1) Facility was not clean and sanitary; floors, bathrooms, kitchen, and grounds were dirty with cigarette butts, garbage, and unsafe items present.
Report Facts
Civil penalty: 250
Civil penalty: 250
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Liza Elegado | Executive Director | Named as unavailable during inspection |
| Delia Perez | Care Supervisor | Met with Licensing Program Analyst during inspection |
| Lori Alexander-Washington | Licensing Program Analyst | Conducted the inspection and authored the report |
| Bennett Fong | Licensing Program Manager | Named in report as Licensing Program Manager |
Inspection Report
Plan of Correction
Census: 49
Capacity: 49
Deficiencies: 2
Date: Oct 2, 2025
Visit Reason
The visit was an unannounced Plan of Correction (POC) inspection to verify correction of deficiencies cited during the annual inspection on 2025-08-28, which had not been cleared by the due dates.
Findings
The facility cleared several deficiencies related to regulations CCR 87411(f), CCR 87303(i)(1)(A), CCR 87303(c), CCR 87506(a), and CCR 87463(a). However, deficiencies related to maintenance and operation of buildings and grounds and reappraisal requirements were not cleared. A repeat violation for maintenance issues was cited with a $250 civil penalty, and an extension was granted for reappraisal updates.
Deficiencies (2)
CCR 87303(a)(1) The facility was not clean or well maintained, with dirty residents' bathrooms, kitchen, hallway carpets, cigarette butts, garbage, plastic gloves, old boxes, and shrubbery posing potential health and safety risks.
CCR 87463(h)(1) The facility did not provide updated reappraisals for residents, but appointments for residents are pending with an extension granted to 2025-10-25.
Report Facts
Civil penalty: 250
Plan of Correction due date: Oct 16, 2025
Plan of Correction due date: Oct 25, 2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Liza Elegado | Executive Director | Met with Licensing Program Analyst during inspection |
| Lori Alexander-Washington | Licensing Program Analyst | Conducted the Plan of Correction visit and signed the report |
| Bennett Fong | Licensing Program Manager | Named in the report as Licensing Program Manager |
Inspection Report
Annual Inspection
Census: 48
Capacity: 49
Deficiencies: 7
Date: Aug 28, 2025
Visit Reason
The inspection was an unannounced 1-Year Annual Required inspection conducted to assess compliance with licensing requirements and facility safety.
Findings
The facility was found to have several deficiencies including missing health screenings for staff, cleanliness issues in bathrooms and common areas, lack of a complete signal system for residents, incomplete resident records, and outdated reappraisals and medical assessments for several residents. Plans of correction were agreed upon with specified due dates.
Deficiencies (7)
CCR 87411(f) Personnel Requirements - General: Health screenings were not on file for staff S3 and S8, posing a potential health and safety risk.
CCR 87303(a)(1) Maintenance and Operation: Residents' bathrooms, kitchen, and hallway carpets were not clean, posing a potential health and safety risk.
CCR 87303(c) Maintenance and Operation: Windows, window blinds, and shades were not cleaned and sanitized, posing a potential health and safety risk.
CCR 87303(i)(1)(A) Maintenance and Operation: The facility lacked a signal system operating from each resident's living unit, posing a potential health and safety risk.
CCR 87506(a) Resident Records: Resident R8's file was incomplete, missing admission agreement, consent form, and appraisal needs and services.
CCR 87463(a) Reappraisals: Current Appraisal Needs and Services were missing for residents R4, R5, R6, R8, R9, and R11, posing a potential health and safety risk.
CCR 87463(h)(1) Reappraisals: Updated medical assessments were missing for residents R4, R5, R8, and R9, posing a potential health and safety risk.
Report Facts
Capacity: 49
Census: 48
Hospice waiver capacity: 10
Deficiency count: 7
Civil penalty: 250
Inspection Report
Complaint Investigation
Census: 48
Capacity: 49
Deficiencies: 0
Date: Mar 12, 2025
Visit Reason
The visit was an unannounced complaint investigation conducted in response to allegations received on 2024-06-05 regarding resident care issues at Pleasant Hill Oasis.
Complaint Details
The complaint investigation was unsubstantiated. Allegations included a resident sustaining unexplained injury, hygiene needs not being met, staff not ensuring clean clothes, and inappropriate bed linens. Interviews with witnesses, residents, and staff, as well as document reviews, did not support the allegations.
Findings
All allegations including unexplained injury, unmet hygiene needs, unclean clothes, and inappropriate bed linens were found to be unsubstantiated after interviews and document reviews.
Report Facts
Facility Capacity: 49
Resident Census: 48
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Liza Elegado | Executive Director | Met during investigation and named as facility representative |
| Lori Alexander-Washington | Licensing Program Analyst | Conducted the complaint investigation |
Inspection Report
Complaint Investigation
Census: 48
Capacity: 49
Deficiencies: 0
Date: Mar 12, 2025
Visit Reason
The visit was an unannounced complaint investigation triggered by allegations received on 2024-10-16 regarding staff conduct and resident care at Pleasant Hill Oasis.
Complaint Details
The complaint involved three allegations: staff did not accord resident dignity in personal relationships, staff did not return resident’s laundry in a timely manner, and staff spoke to resident in an inappropriate manner. Each allegation was investigated through interviews with witnesses and staff, and all were found unsubstantiated due to lack of preponderance of evidence.
Findings
All allegations including staff not according resident dignity, untimely return of resident laundry, and inappropriate staff communication were found to be unsubstantiated after interviews and document review.
Report Facts
Facility Capacity: 49
Resident Census: 48
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Liza Elegado | Executive Director | Met with Licensing Program Analyst during investigation and named in report |
| Lori Alexander-Washington | Licensing Program Analyst | Conducted complaint investigation and interviews |
Inspection Report
Complaint Investigation
Census: 48
Capacity: 49
Deficiencies: 2
Date: Mar 12, 2025
Visit Reason
The visit was an unannounced complaint investigation triggered by a complaint received on 2025-01-15 regarding facility conditions and care concerns at Pleasant Hill Oasis.
Complaint Details
The complaint investigation was substantiated for allegations that the licensee did not ensure the facility was free of roaches and did not ensure the community toilet was in good repair. Other allegations about food service, resident toilet access, and night supervision staffing were unsubstantiated.
Findings
Two allegations were substantiated: the facility was not free of roaches and the community toilet was not properly anchored and in good repair. Three other allegations related to food service adequacy, resident access to toilet in room, and night supervision staffing were unsubstantiated.
Deficiencies (2)
CCR 80087(a)(1): The facility was not free of roaches, including in residents' bedrooms, posing a potential health and safety risk.
CCR 87303(a): The community toilet was not properly anchored to the floor and the area was not clean and sanitized, posing a potential health and safety risk.
Report Facts
Facility Capacity: 49
Census: 48
Deficiency Count: 2
Plan of Correction Due Date: May 28, 2025
Plan of Correction Due Date: Apr 9, 2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Liza Elegado | Executive Director | Met with Licensing Program Analyst during inspection and named in findings |
| Lori Alexander-Washington | Licensing Program Analyst | Conducted complaint investigation and authored report |
Inspection Report
Complaint Investigation
Census: 48
Capacity: 49
Deficiencies: 0
Date: Mar 12, 2025
Visit Reason
The visit was an unannounced complaint investigation conducted in response to allegations that staff did not follow the directives of a resident's doctor and that staff were not able to effectively communicate with residents.
Complaint Details
The complaint investigation was triggered by allegations that staff did not follow the directives of a resident's doctor and that staff were not able to effectively communicate with residents. Both allegations were unsubstantiated based on interviews and document review.
Findings
Both allegations were found to be unsubstantiated after interviews with witnesses and staff, and review of relevant documents. There was no preponderance of evidence to prove the alleged violations occurred.
Report Facts
Capacity: 49
Census: 48
Inspection Report
Complaint Investigation
Census: 49
Capacity: 49
Deficiencies: 0
Date: Jan 9, 2025
Visit Reason
The visit was an unannounced complaint investigation conducted in response to a complaint received on 2023-04-18 regarding questionable death at the facility.
Complaint Details
The complaint allegation was related to a questionable death of a resident. After review of medical records, interviews with staff, and observations, the allegation was determined to be unsubstantiated due to lack of evidence proving the alleged violation.
Findings
The investigation included interviews and review of resident medical documents. The allegation of questionable death was found to be unsubstantiated as there was no evidence of neglect or lack of care by facility staff.
Report Facts
Capacity: 49
Census: 49
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Liza Elegado | Executive Director | Met with Licensing Program Analyst during investigation and exit interview |
| Lori Alexander-Washington | Licensing Evaluator | Conducted complaint investigation |
| Bennett Fong | Supervisor | Supervisor overseeing the investigation |
Inspection Report
Follow-Up
Census: 49
Capacity: 49
Deficiencies: 1
Date: Jan 9, 2025
Visit Reason
The visit was an unannounced Case Management inspection to review the status of previously cited deficiencies from an Annual Inspection and Plan of Correction visits.
Findings
Several deficiencies cited during the prior Annual Inspection were cleared, but one deficiency related to outdated medical assessments was not cleared. An immediate civil penalty was assessed for the repeat violation.
Deficiencies (1)
CCR 87458(c): The licensee failed to obtain updated medical assessments as required, with Physician's Reports over a year old for residents R1 and R2, posing potential health and safety risks.
Report Facts
Immediate Civil Penalty: 250
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Liza Elegado | Executive Director | Met with Licensing Program Analyst during the inspection. |
| Lori Alexander-Washington | Licensing Evaluator | Conducted the inspection and signed the report. |
| Bennett Fong | Supervisor | Supervisor overseeing the inspection. |
Inspection Report
Plan of Correction
Census: 48
Capacity: 49
Deficiencies: 2
Date: Nov 1, 2024
Visit Reason
The visit was an unannounced Plan of Correction (POC) inspection conducted because the facility failed to submit the required POC by the due dates following an Annual visit where deficiencies were cited.
Findings
Several deficiencies cited during the prior Annual visit were cleared, but two deficiencies remained uncorrected. Civil penalties totaling $700 were assessed for failure to meet POC deadlines, with ongoing daily penalties until corrections are made.
Deficiencies (2)
87211(a)(1) deficiency was not cleared and resulted in a $600 civil penalty due to failure to meet the POC deadline.
87458(C) deficiency was not cleared and resulted in a $100 civil penalty due to failure to meet the POC deadline.
Report Facts
Civil Penalties Assessed: 700
Civil Penalty for 87211(a)(1): 600
Civil Penalty for 87458(C): 100
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Liza Elegado | Executive Director | Met with Licensing Program Analysts during the POC visit. |
| Reynaldo Gutierrez | Business Office Manager | Explained the purpose of the visit to Licensing Program Analysts. |
Inspection Report
Annual Inspection
Census: 48
Capacity: 49
Deficiencies: 12
Date: Oct 8, 2024
Visit Reason
The inspection was an unannounced 1-Year Annual Required inspection to evaluate compliance with licensing regulations and facility safety standards.
Findings
The inspection identified multiple deficiencies including failure to transfer criminal record clearance, incomplete resident files, outdated medical assessments, lack of required staff training and certifications, and facility maintenance issues such as unclean and disrepair conditions. Plans of correction were submitted with due dates ranging from October to November 2024.
Deficiencies (12)
CCR 87355(e)(3) Criminal Record Clearance was not transferred and associated for S3, posing an immediate health and safety risk.
CCR 87463(a) Pre-admission appraisals were not updated for residents R2-R9, risking inaccurate documentation of significant changes.
CCR 87623(b)(2)(B) Documentation for Foley catheter care for residents R7 and R9 was incomplete, lacking home health care plans and trained staff records.
CCR 87211(a)(1) Notification to licensing was not sent when resident R6 was hospitalized, posing an immediate health and safety risk.
CCR 87458(c) Medical assessments were outdated for residents R2, R3, R4, R6, R7, and R9, risking health and safety.
CCR 87506(a)(b) Resident file for R6 was incomplete, missing key documents including Admission Agreement and Physician's Report.
CCR 87303(a)(1)(c) Facility was not clean or in good repair; furniture and equipment were improperly stored outside and flooring and window screens were dirty or damaged.
HSC 1569.618(c)(3) Staff S3-S9 lacked updated First Aid and CPR training certificates.
CCR 87411(f) Health screenings and TB tests were missing for staff S3, S7, and S9, posing health risks.
HSC 1569.625(b)(2) Annual training requirements, including dementia care and hospice care, were not completed for staff S2-S9.
CCR 87458(b)(1) Negative TB test was not on file for resident R5, posing a health and safety risk.
CCR 87555(b)(16) Food service staff S4 did not have a current Food Safety certificate; the certificate expired in 2021.
Report Facts
Immediate civil penalty: 500
Facility capacity: 49
Census: 48
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Liza Elegado | Executive Director | Met with Licensing Program Analyst during inspection and involved in plan of correction for criminal record clearance. |
Inspection Report
Annual Inspection
Capacity: 49
Deficiencies: 0
Date: Sep 12, 2023
Visit Reason
The visit was an unannounced 1-Year Annual Required inspection conducted to evaluate the facility's compliance with licensing requirements.
Findings
The facility was toured and various safety and care aspects were reviewed, including resident apartments, bathrooms, and staff records. No deficiencies were cited during the visit.
Report Facts
Hospice waiver capacity: 10
Residents records reviewed: 10
Staff records reviewed: 7
Staff with current first aid training: 7
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Liza Elegado | Executive Director | Met with Licensing Program Analyst during inspection |
Inspection Report
Plan of Correction
Census: 44
Capacity: 44
Deficiencies: 2
Date: May 11, 2023
Visit Reason
Unannounced proof of correction (POC) inspection to verify correction of previously cited deficiencies from a case management visit on 04/28/2023.
Findings
The previously cited deficiencies regarding fire clearance for a resident's room and facility maintenance issues with unlocked sheds and weathered doors were corrected. Locks were placed on sheds and doors, weathered doors were replaced, and accumulated items outside were removed and cleaned up.
Deficiencies (2)
87202(a): Resident was occupying a room without fire clearance. The resident was moved and the room was cleared.
87307(d)(2): Facility exterior was not maintained with unlocked sheds, weathered doors, and miscellaneous disrepair. Locks were placed on sheds and doors, weathered doors replaced, and exterior cleaned.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Reynaldo Gutierrez | Business Office Manager | Met with Licensing Program Analyst and Manager during inspection. |
Inspection Report
Census: 44
Capacity: 44
Deficiencies: 0
Date: May 11, 2023
Visit Reason
The visit was an unannounced Case Management regarding ongoing discussion pertaining to a capacity increase and proposed physical plant changes.
Findings
The Licensing Program Analyst and Manager reviewed proposed physical plant modifications including converting staff and conference rooms into shared resident rooms and modifying bathrooms. No deficiencies were cited, and the facility was advised to obtain necessary permits and submit required documentation for the alterations.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Reynaldo Gutierrez | Business Office Manager | Met with Licensing Program Analyst and Manager during the visit. |
Inspection Report
Complaint Investigation
Census: 44
Capacity: 44
Deficiencies: 3
Date: Apr 28, 2023
Visit Reason
The visit was conducted unannounced as a health and safety check triggered by a complaint received by the department.
Complaint Details
The visit was triggered by a complaint received by the department. The complaint was substantiated as deficiencies were found during the health and safety check.
Findings
The inspection found multiple deficiencies including accessible toxic substances, items stored improperly in outdoor areas, weathered doors missing knobs, unlocked electrical room door, and a storage room being used as living space without proper clearance.
Deficiencies (3)
CCR 87705(f)(2): Toxic substances such as cleaning supplies and disinfectants were accessible to residents, evidenced by a disinfectant spray bottle under the sink in the shower room.
CCR 87307(d)(2): The facility was not maintained in a state of good repair, with weathered doors missing knobs and locks, and items stored in back and side yards.
CCR 87202(a): The facility failed to maintain an approved fire clearance as a storage room was used as living space prior to clearance, posing a potential health and safety risk.
Report Facts
Census: 44
Total Capacity: 44
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Liza Elegado | Administrator | Met with Licensing Program Analysts during inspection and involved in plan of correction |
Inspection Report
Census: 42
Capacity: 44
Deficiencies: 0
Date: Apr 19, 2023
Visit Reason
The visit was an unannounced Case Management regarding a capacity increase at the facility.
Findings
The Licensing Program Analysts toured the facility and reviewed plans for increasing capacity by 5 residents, including converting a single room to a shared room and constructing new rooms. Ownership changes were also discussed and documented.
Report Facts
Capacity increase request: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Liza Elegado | Executive Director | Met with Licensing Program Analysts during the visit |
| Lori Alexander-Washington | Licensing Evaluator | Conducted the inspection |
| Bennett Fong | Supervisor | Supervisor overseeing the inspection |
Inspection Report
Routine
Census: 43
Capacity: 44
Deficiencies: 0
Date: Sep 7, 2022
Visit Reason
The visit was an unannounced infection control inspection conducted as a required one-year routine check.
Findings
The inspection found the facility compliant with infection control standards, including proper screening, signage, PPE availability, and staff mask usage. No deficiencies were cited during the visit.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Reynaldo Gutierrez | Business Office Manager | Met with Licensing Program Analyst during the inspection. |
Inspection Report
Complaint Investigation
Census: 44
Capacity: 44
Deficiencies: 0
Date: Dec 9, 2021
Visit Reason
The visit was an unannounced complaint investigation regarding an allegation that staff failed to treat residents with dignity and respect.
Complaint Details
The complaint alleging staff failed to treat residents with dignity and respect was investigated and found unsubstantiated.
Findings
The investigation found that staff did not intentionally raise their voices or yell at residents except when necessary to stop arguments or get attention. Most residents stated that staff respected and took care of them well. The allegation was unsubstantiated due to lack of preponderance of evidence.
Report Facts
Capacity: 44
Census: 44
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Liza Elegado | Administrator | Met with during the investigation |
| Reynaldo Gutierrez | Business Office Manager | Authorized to sign the report |
| Catherine Lin | Licensing Program Analyst | Conducted the complaint investigation |
| Bennett Fong | Supervisor | Supervisor overseeing the investigation |
Inspection Report
Complaint Investigation
Census: 44
Capacity: 44
Deficiencies: 0
Date: Nov 8, 2021
Visit Reason
The visit was an unannounced complaint investigation triggered by an allegation that facility staff locked a resident in their room.
Complaint Details
The complaint alleged that facility staff locked a resident in their room. The investigation found no preponderance of evidence to prove the violation occurred, and the allegation was unsubstantiated.
Findings
The investigation found that although a latch was placed outside the resident's door, the sliding glass door allowed the resident to leave the room and was not locked from the outside. The allegation was unsubstantiated due to lack of evidence.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Grace Luk | Licensing Program Analyst | Conducted the complaint investigation and delivered findings. |
| Liza Elegado | Executive Director | Facility representative met during investigation. |
| Delia Perez | Staff interviewed during investigation. |
Inspection Report
Annual Inspection
Census: 42
Capacity: 44
Deficiencies: 0
Date: Sep 21, 2021
Visit Reason
The visit was an infection control annual inspection conducted to evaluate compliance with COVID-19 infection control practices and overall facility safety.
Findings
No deficiencies were cited during the visit. The facility had a completed COVID-19 mitigation plan, adequate PPE supplies, proper medication and chemical storage, and maintained emergency food supplies and operational safety equipment.
Report Facts
Days of nonperishable food supply: 7
Days of perishable food supply: 2
Administrator onsite hours per week: 20
Facility capacity: 44
Facility census: 42
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