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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 435202898
Report Date: 05/27/2026
Date Signed: 09/03/2026 03:35:11 PM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CENTRAL COAST CR/RES, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131
This is an official report of an unannounced visit/investigation of a complaint received in our office on
09/19/2025 and conducted by Evaluator Maria Partoza
COMPLAINT CONTROL NUMBER: 26-AS-20250919082938
FACILITY NAME:OAKMONT OF SILVER CREEKFACILITY NUMBER:
435202898
ADMINISTRATOR:HOLLY SUITERFACILITY TYPE:
740
ADDRESS:3544 SAN FELIPE ROADTELEPHONE:
(669) 200-2442
CITY:SAN JOSESTATE: CAZIP CODE:
95135
CAPACITY:148CENSUS: 89DATE:
05/27/2026
UNANNOUNCEDTIME BEGAN:
01:40 PM
MET WITH:Minnie WeberTIME COMPLETED:
05:28 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
1- Staff restrained resident while in care
2 - Staff did not ensure sharps are not accessible to resident
3 - Staff did not provide resident care and supervision, resulting in resident sustaining an injury
4 - Staff did not distribute resident's medication as prescribed
5 - Staff did not ensure that resident's dietary needs were met
7 - Staff did not respond to resident's call alarm system in a timely manner
8 - Staff did not provide housekeeping service when needed
9 - Staff did not provide assistance to resident in care when needed
Allegation 6, 10, 11, 12 and 13 are continued in LIC 9099A
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
This report is being amended due to addtional information received

On 05/27/2026 at 1:40 p.m. Licensing Program Analyst (LPA) Maria (Mita) Partoza conducted an unannounced complaint visit and met with Executive Director (ED/ADM) Minnie Weber. LPA stated the purpose of the visit.

ON 09/19/2025, the Department received a complaint with the above allegations (total of 13 allegations).
LPA conducted initial investigation on 09/24/2025, interviewed staff and gathered information pertaining to the allegations.

Page 1
LIC 9099C

Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Maria Partoza
LICENSING EVALUATOR SIGNATURE:

DATE: 09/02/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/02/2026
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 12
Control Number 26-AS-20250919082938
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CENTRAL COAST CR/RES, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131
FACILITY NAME: OAKMONT OF SILVER CREEK
FACILITY NUMBER: 435202898
VISIT DATE: 05/27/2026
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
This report is being amended due to additional information.
On 10/15/25, 01/21/26, 01/29/26, 01/30/26, 02/05/26, 02/26/26, 04/30/26, and 05/27/26 LPA conducted inspections visits, and staff interviews.
Allegation 1 Staff restrained resident in wheelchair.
On 09/24/2025, LPA interviewed reporting party (RP). RP stated resident 1 (R1) required assistance with ambulation; however, staff allegedly avoided assisting R1 by pushing R1’s wheelchair against a wall and placing a table against the wheelchair to keep R1 seated.
On 10/15/25, 01/21/26, 01/29/26, 01/30/26, and 03/26/26, LPA interviewed staff 1 through 5 (S1, S2, S3, S5), and former staff 1 (FS1). S1, S2, S3, S5, and FS1 stated R1 required increased supervision, redirection, and monitoring due to fall risk and repeated attempts to stand without assistance. S1 stated residents with mobility instability/unsteady gait may be seated at the dining table while staff assisting residents during mealtime. S2 stated dining tables in the memory care unit were movable and R1 was able to move away from the table. S3, S5, and FS1 stated staff did not use restraint interventions as part of resident care. Five of five staff described R1 as restless and repeatedly attempting to stand from a seated position without assistance, requiring frequent redirection and supervision due to fall risk. S1, S3, S5, and FS1 stated the wheelchair wheels were locked while R1 was seated at the dining table to prevent the wheelchair from sliding and causing injury. S3, S5, and FS1 stated staff did not restrain R1.
On 10/15/2025 and 02/05/2026, LPA conducted observations of the memory care dining area. LPA observed the dining tables were movable, chairs allowed wheelchair maneuverability, and tables were not positioned against the wall. On
02/05/2026, LPA did not observe any resident positioned against a wall with a dining table placed in front of the wheelchair.

Allegation 2 Staff did not ensure dangerous items were inaccessible to resident
On 09/24/2025, LPA interviewed RP. RP stated that on 05/10/2025, staff did not provide adequate supervision to another resident, and RP observed the resident take a knife from the dining room to the resident’s room without staff knowledge. RP stated the incident was reported to staff, who confiscated the knife from the resident.

Staff interviews were conducted on 10/15/2025, 01/21/2026, 01/29/2026, 01/30/2026, and 03/26/2026. LPA interviewed S1,S2, S3, S5, and FS1 regarding utensil access and resident safety. S1, S2, S3, S5, and FS1 stated residents were provided standard dining utensils during meal service. S2 stated residents may have access to butter knives used during meals and staff were present assisting residents during mealtime. Five of five staff stated dining utensils were provided during meal service. Staff identified dining utensils as spoons, forks, and butter knives and stated sharp kitchen knives were not accessible to Memory Care residents. Based on documents reviewed, LPA reviewed incident documentation related to the reported knife incident. The Incident Report stated staff retrieved the utensil and no resident injury was reported. page 2
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Maria Partoza
LICENSING EVALUATOR SIGNATURE:

DATE: 09/02/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/02/2026
LIC9099 (FAS) - (06/04)
Page: 2 of 12
Control Number 26-AS-20250919082938
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CENTRAL COAST CR/RES, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131
FACILITY NAME: OAKMONT OF SILVER CREEK
FACILITY NUMBER: 435202898
VISIT DATE: 05/27/2026
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
This report is being amended due to additional information
Allegation 3 Staff did not provide adequate supervision resulting in resident falls
On 09/24/2025, LPA interviewed reporting party (RP). RP stated R1 experienced multiple falls, including incidents on 03/17/2025 and 04/09/2025, resulting in injuries requiring medical evaluation, and alleged staff did not provide adequate supervision.

Staff interviews were conducted on 10/15/2025, 01/21/2026, 01/29/2026, 01/30/2026, and 03/26/2026. LPA interviewed S1, S2, S3, S5, and former staff 1 (FS1), who stated R1 exhibited impulsive behaviors, repeatedly attempted to stand without assistance, resisted redirection, and required increased supervision due to declining condition and behavioral changes.

Based on documents reviewed, LPA reviewed chart notes, incident reports, assessments, hospice documentation, and care conference records related to R1’s falls and supervision needs. Records reviewed documented falls on 03/17/2025 and 04/09/2025, staff monitoring, behavioral redirection, increased supervision interventions, physician notification, medical evaluation, hospice involvement, and reassessment of R1’s care needs related to R1’s declining condition and fall risk. Documents reviewed stated R1 had repeated attempts to stand without assistance, behavioral changes, fall risk, and
increased supervision and redirection needs, as also stated by S1, S2, S3, S5, and FS1.

Allegation 4 Staff did not distribute/administer resident’s medication as prescribed
On 09/24/2025, LPA interviewed reporting party (RP). RP stated staff did not administer R1’s medications as prescribed,
alleging staff overmedicated R1 multiple times, administered additional sedating medications to manage behaviors, crushed R1’s medications without confirmed physician authorization, and reported that on 07/20/2025, R1 consumed medication and later became drowsy.

Staff interviews were conducted on 01/21/2026, 01/30/2026, 02/02/2026, and 03/26/2026 to determine medication
administration practices and whether medication changes were implemented pursuant to physician orders. LPA interviewed S2, S3, former staff 1 (FS1), and hospice staff (HS). S2 stated medication staff verified the resident’s name, medication label, dosage, and quantity prior to administration. S3 stated medications were administered pursuant to physician orders/directions and could not be started, stopped, or changed without physician direction. FS1 and HS stated R1 experienced physician- and hospice-directed medication adjustments related to R1’s care needs. FS1 and HS stated the medication changes were made as R1’s condition and behaviors changed and were implemented pursuant to physician's direction.

page 3
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Maria Partoza
LICENSING EVALUATOR SIGNATURE:

DATE: 09/02/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/02/2026
LIC9099 (FAS) - (06/04)
Page: 3 of 12
Control Number 26-AS-20250919082938
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CENTRAL COAST CR/RES, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131
FACILITY NAME: OAKMONT OF SILVER CREEK
FACILITY NUMBER: 435202898
VISIT DATE: 05/27/2026
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
This report is being amended due to additional information received
Based on documents reviewed, LPA reviewed Medication Administration Records (MAR), physician medication orders,
hospice documentation, Centrally Stored Medication and Destruction Records (CSMDR), and chart notes. Records reviewed documented physician directed medication changes, scheduled medication administration, and PRN medication
administration pursuant to physician orders. The Medication Administration Record (MAR) and physician medication orders documented the medications, dosages, and administration instructions prescribed for R1, while chart notes and hospice documentation stated medication changes were made pursuant to physician direction based on R1’s changing care needs.
Allegation 5 Staff did not ensure resident’s dietary needs were met
On 09/24/2025, LPA interviewed RP. RP stated food was found on R1’s clothing or on the floor, R1 was not consistently
assisted with feeding, R1 lacked motor skills to feed independently, and other residents were observed waiting more than an hour for feeding assistance.
Staff interviews were conducted on 10/15/2025, 01/21/2026, 01/29/2026, 01/30/2026, and 03/26/2026. LPA interviewed S1, S2, S3, S5, and FS1. S1, S2, S3, S5, and FS1 stated meals were prepared and offered to R1 based on R1’s care needs. S2 stated staff assisted residents who required feeding assistance. S2, S3, S5, and FS1 stated R1 received feeding assistance during meals; S5 stated R1 could eat finger foods independently, and HS stated hospice monitored R1’s dietary intake.
Based on documents reviewed, LPA reviewed chart notes documenting R1 ate meals with staff supervision, encouragement to remain seated during mealtime, feeding assistance, and food intake. Chart notes also documented hospice recommendations related to R1’s nutritional care. Record review and interviews documented staff provided meal assistance and monitored R1’s food intake. Documents reviewed did not state R1 had physician-ordered dietary restrictions.

Allegation 7 Staff did not respond to resident’s call alarm system in a timely manner
On 09/24/2025, LPA interviewed RP. RP stated staff did not timely respond to the monitoring system used in memory care, allegedly turned off pagers, and RP reported having to contact staff regarding R1’s care needs.

On 10/15/2025, 01/21/2026, 01/29/2026, 01/30/2026, and 03/26/2026, LPA interviewed S1, S2, S3, S5, and FS1 regarding
supervision and alarm-monitoring practices. S1, S2, S3, S5, and FS1 stated residents were monitored through direct
supervision, alarm or sensor monitoring, routine checks, and response to resident alerts based on care needs. LPA
interviewed S2 and S5. S2 stated resident rooms utilized motion sensors from 8:00 PM to 8:00 AM that notified caregivers
through pagers when movement was detected. S5 stated caregivers carried pagers and staff responded based on resident care needs and staff availability. The monitoring system did not maintain staff response-time records for sensor-generated alerts. page 4
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Maria Partoza
LICENSING EVALUATOR SIGNATURE:

DATE: 09/02/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/02/2026
LIC9099 (FAS) - (06/04)
Page: 4 of 12
Control Number 26-AS-20250919082938
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CENTRAL COAST CR/RES, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131
FACILITY NAME: OAKMONT OF SILVER CREEK
FACILITY NUMBER: 435202898
VISIT DATE: 05/27/2026
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
This report is being amended due to additional information received

Allegation 8 Staff did not provide housekeeping service when needed
On 09/24/2025, LPA interviewed RP. RP stated that on 04/05/2025, R1 defecated in R1’s room, smeared
feces on the bed, walls, and bathroom, had feces on R1’s face, and was reportedly eating feces. RP alleged
the room was not fully cleaned until a later date and the family completed additional cleaning.

Staff interviews were conducted on 10/15/2025, 01/30/2026, 02/26/2026, and 03/26/2026. LPA interviewed
S1, S3, S6, and FS1. S1, S3, and FS1 stated cleaning services were available when needed. S6 stated the
incident occurred after hours and care staff completed initial cleaning prior to S6’s arrival. S6 stated he/she
responded in less than one hour, steam cleaned and disinfected the carpet, cleaned the apartment, and
laundering of clothing and bedding was completed.

Based on documents reviewed, LPA reviewed chart notes and facility records related to the reported incident
dated 04/05/2025. Chart notes documented staff observed feces in R1’s mouth, provided hygiene assistance, contacted maintenance for carpet cleaning, and documented maintenance completed carpet cleaning services. Record review and interviews documented staff response and environmental cleaning interventions following the reported incident.

Allegation 9 Staff did not provide assistance when needed
On 09/24/2025, LPA interviewed reporting party (RP). RP stated R1 did not consistently receive needed
supervision, mobility assistance, and behavioral support, resulting in the family obtaining a private 1:1
caregiver due to concerns regarding R1’s care needs.

Staff interviews were conducted on 01/21/2026, 01/29/2026, and 01/30/2026. LPA interviewed S2, S3 and S5. S2 & S3 stated staff monitored and redirected residents based on resident needs. S5 stated memory care staff provided supervision, redirection, and behavioral monitoring for residents requiring additional assistance.

page 5
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Maria Partoza
LICENSING EVALUATOR SIGNATURE:

DATE: 09/02/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/02/2026
LIC9099 (FAS) - (06/04)
Page: 5 of 12
Control Number 26-AS-20250919082938
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CENTRAL COAST CR/RES, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131
FACILITY NAME: OAKMONT OF SILVER CREEK
FACILITY NUMBER: 435202898
VISIT DATE: 05/27/2026
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
This report is being amended due to additional information received

Based on documents reviewed, LPA reviewed LIC 602 forms, assessments, care plan records, and chart
notes related to R1’s care needs. Records reviewed documented supervision, behavioral monitoring,
redirection, mobility assistance, fall prevention interventions, and care planning discussions regarding R1’s
increased care needs. Chart notes documented care staff and medication technicians checked on R1 every
15 to 30 minutes, remained with R1 during periods of agitation, redirected R1 during repeated attempts to
stand without assistance, and monitored R1 overnight.

Record review and interviews documented staff provided supervision and assistance related to R1’s care
needs. Chart notes documented that on 04/02/2025 at approximately 9:40 AM, staff monitored R1 during an
episode of agitation, and on 04/25/2025 at approximately 6:30 PM, staff assisted and remained with R1 during agitation and repeated attempts to stand to prevent a fall.

Although the allegation(s) may have happened or is valid, there is not a preponderance of evidence to prove
the alleged violation(s) did or did not occur, therefore the allegation is unsubstantiated.

No deficiencies cited during today's visit for allegations 1 through 4, 5,7,8 and 9, based on the California Code of Regulations (CCR) Title 22. Exit interview was conducted with ED/ADM Minnie Weber and a copy of the report was provided to ED/ADM Minnie Weber.

page 6
SEE LIC 9099A of continuation for allegations #6. 10, 11, 12 and 13.
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Maria Partoza
LICENSING EVALUATOR SIGNATURE:

DATE: 09/02/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/02/2026
LIC9099 (FAS) - (06/04)
Page: 6 of 12
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CENTRAL COAST CR/RES, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131
This is an official report of an unannounced visit/investigation of a complaint received in our office on
09/19/2025 and conducted by Evaluator Maria Partoza
COMPLAINT CONTROL NUMBER: 26-AS-20250919082938

FACILITY NAME:OAKMONT OF SILVER CREEKFACILITY NUMBER:
435202898
ADMINISTRATOR:HOLLY SUITERFACILITY TYPE:
740
ADDRESS:3544 SAN FELIPE ROADTELEPHONE:
(669) 200-2442
CITY:SAN JOSESTATE:CAZIP CODE:
95135
CAPACITY:148CENSUS: DATE:
05/27/2026
UNANNOUNCEDTIME BEGAN:
01:40 PM
MET WITH:Minnie WeberTIME COMPLETED:
05:28 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
11- Licensee did not ensure staff are receiving proper training in the care and supervision of residents
12- Staff did not provide timely notification to responsible parties (RP) of residents change in condition
13- Staff did not administer medication safely to resident
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
continuation allegations 11, 12, and 13
Allegation 11 Licensee did not ensure staff received proper training in the care and supervision of residents
On 09/24/2025, LPA interviewed reporting party (RP). RP stated concerns regarding staff supervision practices, resident care, medication administration, and staff responses to R1’s care needs.

LPA interviewed S1, S2, and S5 regarding staff training and care practices. S1 stated facility staff received medication-related reminders and training regarding medication administration practices. S2 stated staff completed monthly Relias training modules, hospice agencies conducted in-service training every other month, and Occupational Therapists provided training regarding gait belts, Hoyer lifts, transfers, and resident care techniques. S5 stated new staff completed shadow training and received additional supervision if performance concerns were identified.

PAGE 1A
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Maria Partoza
LICENSING EVALUATOR SIGNATURE:

DATE: 05/27/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/27/2026
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 7 of 12
Control Number 26-AS-20250919082938
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CENTRAL COAST CR/RES, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131
FACILITY NAME: OAKMONT OF SILVER CREEK
FACILITY NUMBER: 435202898
VISIT DATE: 05/27/2026
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
Based on documents reviewed, LPA reviewed available staff training records, facility records, assessments, care planning records, and chart notes related to R1’s care needs. Records reviewed documented staff discussions regarding behavioral interventions, supervision needs, resident monitoring, fall prevention interventions, and hospice coordination. Record review and interviews documented staff received training related to resident care and supervision.

Allegation 12 Staff did not provide timely notification to responsible party of resident’s change in condition

On 09/24/2025, LPA interviewed reporting party (RP). RP stated concerns regarding communication and notification of incidents, condition changes, medical events, and care concerns involving R1.

LPA interviewed S1, S2, S3, FS1, and hospice care staff regarding communication practices. S1 stated family meetings occurred regarding R1’s changing care needs and supervision concerns. S2 stated staff notified the physician and responsible party regarding condition changes and completed alert charting related to resident status changes. S3 stated staff notified responsible parties, hospice, and physicians regarding incidents and resident condition changes. FS1 stated facility staff communicated incidents, condition changes, and care concerns to responsible parties. Hospice care staff stated hospice communicated with family and care providers regarding physician-directed care and condition changes.

Based on documents reviewed, LPA reviewed chart notes, incident reports, hospice documentation, communication records, assessment records, and care conference documentation related to R1’s condition and care needs. Records reviewed documented communication with responsible parties regarding incidents, falls, medical evaluations, hospice involvement, physician notification, reassessment of care needs, and changes in R1’s condition, including a documented care conference with family on 04/09/2025 regarding supervision concerns, behavioral changes, fall risk, and care planning discussions, hospice evaluation on 04/10/2025, and hospice admission on 04/11/2025. Record review and interviews documented facility staff communicated resident condition changes and care concerns to responsible parties.

page 2A
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Maria Partoza
LICENSING EVALUATOR SIGNATURE:

DATE: 05/27/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/27/2026
LIC9099 (FAS) - (06/04)
Page: 8 of 12
Control Number 26-AS-20250919082938
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CENTRAL COAST CR/RES, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131
FACILITY NAME: OAKMONT OF SILVER CREEK
FACILITY NUMBER: 435202898
VISIT DATE: 05/27/2026
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
Allegation 13 Staff did not distribute/administer resident’s medication properly

On 09/24/2025, LPA interviewed reporting party (RP). RP stated concerns regarding medication administration practices, including observations that transdermal medication patches were not consistently removed prior to application of new patches, resulting in concerns regarding improper medication administration. Private Care Giver (PCG) stated observations were made involving multiple transdermal medication patches remaining in place.

LPA interviewed S1, S2, S3, former staff 1 (FS1), and hospice care staff regarding medication administration practices. S1 stated hospice was consulted regarding concerns involving multiple transdermal medication patches and staff received follow-up medication reminders. S2 stated medication staff verified the resident’s name, medication label, dosage, and quantity prior to medication administration. S3 stated medications were administered pursuant to physician orders and staff could not independently start, stop, or change medications without physician direction. FS1 and hospice care staff stated medication changes occurred pursuant to physician- and hospice-directed care.

Based on documents reviewed, LPA reviewed Medication Administration Records (MAR), physician medication orders, hospice documentation, Centrally Stored Medication and Destruction Records (CSMDR), and chart notes related to transdermal medication administration. Records reviewed documented physician- and hospice-directed medication management related to R1’s care. Records reviewed did not document a physician or hospice statement that retained transdermal medication patches caused increased agitation or other adverse outcome. Records reviewed did not document a written MAR instruction requiring removal of the previous transdermal medication patch prior to application of a new patch. Interviews documented concerns that multiple transdermal medication patches remained in place and that staff received follow-up reminders. Record review and interviews documented medication administration are followed pursuant to physician- and hospice-directed orders.

No deficiencies cited during today's visit for allegations 11, 12, 13 based on the California Code of Regulations (CCR) Title 22. Exit interview was conducted with ED/ADM Minnie Weber and a copy of the report was provided to ED/ADM.
PAGE 3A
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Maria Partoza
LICENSING EVALUATOR SIGNATURE:

DATE: 05/27/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/27/2026
LIC9099 (FAS) - (06/04)
Page: 9 of 12
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CENTRAL COAST CR/RES, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131
This is an official report of an unannounced visit/investigation of a complaint received in our office on
09/19/2025 and conducted by Evaluator Maria Partoza
COMPLAINT CONTROL NUMBER: 26-AS-20250919082938

FACILITY NAME:OAKMONT OF SILVER CREEKFACILITY NUMBER:
435202898
ADMINISTRATOR:HOLLY SUITERFACILITY TYPE:
740
ADDRESS:3544 SAN FELIPE ROADTELEPHONE:
(669) 200-2442
CITY:SAN JOSESTATE:CAZIP CODE:
95135
CAPACITY:148CENSUS: DATE:
05/27/2026
UNANNOUNCEDTIME BEGAN:
01:40 PM
MET WITH:Minnie WeberTIME COMPLETED:
05:28 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
6 - Staff did not document observation of resident's change in condition while in care
10 - Staff did not appraise resident accurately prior to admission resulting to incorrect level of care being provided
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
CONTINUED FROM LIC 9099 - Allegations 6 and 10.

Allegation 6 Staff did not document observation of resident’s change in condition
On 09/24/2025, LPA interviewed RP. RP stated R1 experienced declining condition, behavioral changes, falls, increased care needs, and hospice involvement that were allegedly not properly documented.

LPA interviewed S1, S2, S3, S5, and former staff 1 (FS1). Staff stated R1 experienced behavioral changes, falls, increased supervision needs, medication changes, and hospice involvement as R1’s condition changed.

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Unfounded
Estimated Days of Completion:
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Maria Partoza
LICENSING EVALUATOR SIGNATURE:

DATE: 05/27/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/27/2026
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
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Control Number 26-AS-20250919082938
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CENTRAL COAST CR/RES, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131
FACILITY NAME: OAKMONT OF SILVER CREEK
FACILITY NUMBER: 435202898
VISIT DATE: 05/27/2026
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
Based on documents reviewed, LPA reviewed assessments, chart notes, hospice documentation, incident reports, and care conference records related to R1’s condition and care needs. Records reviewed documented reassessment of R1’s care needs, behavioral changes, falls, medication changes, increased supervision needs, hospice involvement, and care planning discussions regarding R1’s changing condition. Records reviewed further documented a pre-assessment dated 03/14/2025, initial assessment dated 03/15/2025, periodic assessment dated 04/07/2025, hospice evaluation on 04/10/2025, hospice admission on 04/11/2025, and a care conference dated 05/23/2025 regarding R1’s condition and care needs.

Allegation 10 Staff did not appraise/reassess resident accurately based on changing care needs
On 09/24/2025, LPA interviewed reporting party (RP). RP stated R1’s care needs increased significantly, including increased falls, behavioral escalation, supervision needs, and hospice involvement, and alleged the facility did not appropriately reassess R1’s changing care needs.

LPA interviewed S1, S3, and former staff 1 (FS1). S1 stated that when R1 transitioned to the memory care unit on 03/15/2025, facility staff completed an assessment, however, S1 stated he/she do not have a record if staff and former Executive Director (FED) conducted a care conference with the family; FS1 stated R1 was assessed upon transition to memory care and R1’s condition changed over time, requiring increased supervision and care. S3 stated R1’s care needs, supervision needs, and behavioral changes were reviewed as R1’s condition changed.

Based on documents reviewed, LPA reviewed assessment records, chart notes, Physician’s Report (LIC 602), care planning documentation, hospice records, and care conference documentation related to R1’s changing care needs. Records reviewed documented reassessment of R1’s care needs, supervision needs, behavioral changes, falls, hospice involvement, and care planning discussions regarding R1’s changing condition. Records further documented a pre-assessment dated 03/14/2025, initial assessment dated 03/15/2025, periodic assessment dated 04/07/2025, hospice evaluation on 04/10/2025, hospice admission on 04/11/2025, and a care conference dated 05/23/2025 regarding R1’s condition and care needs. Records reviewed also documented assessment reviews and care plan updates that were approved, rejected, or refused during the reassessment process dating from 08/11/2022 to 07/01/2025.

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SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Maria Partoza
LICENSING EVALUATOR SIGNATURE:

DATE: 05/27/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/27/2026
LIC9099 (FAS) - (06/04)
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Control Number 26-AS-20250919082938
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CENTRAL COAST CR/RES, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131
FACILITY NAME: OAKMONT OF SILVER CREEK
FACILITY NUMBER: 435202898
VISIT DATE: 05/27/2026
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
This agency has investigated the complaint alleging staff did not document observation of resident’s change in condition and staff did not appraise/reassess resident accurately based on changing care needs. We have found that the complaint was unfounded, meaning the allegation was false, could not have happened, and/or is without a reasonable basis.

No deficiencies were cited during today's visit for allegation 6 and 10 based on the California Code of Regulations (CCR) Title 22 and a copy of the report was provided to Executive Director/ADM Minnie Weber.

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SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Maria Partoza
LICENSING EVALUATOR SIGNATURE:

DATE: 05/27/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/27/2026
LIC9099 (FAS) - (06/04)
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