Incident investigation·September 5, 2025

On September 5, 2025, LPA Pang Lee conducted an unannounced case management visit to Oakmont of East Sacramento. Upon arrival, LPA met with Executive Director (ED) Kathlee Gilbey and explained the purpose of the visit, which was to gather additional information and facility documentation related to a SOC 341 report dated August 18, 2025, and received by Community Care Licensing Division (CCLD) via fax on August 19, 2025. According to the SOC 341 report, a resident's wife observed Resident 1 (R1) engaging in sexually inappropriate behavior with another resident (R2) while seated on a couch in a common area. Additionally, it was reported that R1 has previously had inappropriate sexual interactions with multiple female residents at the facility. The ED and Memory Care Director Kelli Hendrix (MCD) reported that a safety plan has been implemented upon discovering of R1’s behavior to address the behavior of R1 with R1’s responsible party to ensure the well-being of R1 and other residents. During the visit, it was learned that R1 has moved out of the facility. LPA Lee collected the following documentation for further review and investigation: For Resident 1 (R1): · Admission Agreement CONTINUED LIC 809-C · LIC 624 – Incident Reports · Charting Notes · Medication List For Residents 2 (R2) and 3 (R3): · LIC 602 – Physician’s Report · LIC 625 – Needs and Services Plan · Charting Notes · LIC 624 – Incident Reports · Admission Agreement Per California Code of Regulations, Title 22, no deficiencies were cited. Exit interview conducted and a copy of this report was left at the facility.