Incident investigation·February 10, 2026

On 02/10/2026, Licensing Program Analyst (LPA) Pang Lee arrived unannounced to the facility to conduct a case management visit in regard to incident reports received. LPA Lee met with Executive Director (ED) Kathleen Gilbey and explained the purpose of the visit. The census is 151. On 08/18/2025, the Sacramento South Adult and Senior Care (ASC) Regional Office (RO) received a self-reported incident from Oakmont of East Sacramento involving Resident 1 (R1), who reportedly engaged in two separate sexual relationships with Resident 2 (R2) and Resident 3 (R3) while residing at the facility. During an interview, R2 denied knowing R1 and stated that the reported incidents never occurred. R2 further indicated that nothing inappropriate happened and denied being forced to participate in any activity against R2’s will. R3 did not respond to interview questions and was unresponsive during the interview. I t was learned that R1 had moved out of the facility on 08/19/2025 . A review of facility records indicates that staff were aware of R1’s inappropriate and sexualized behaviors and were actively addressing the concerns. Documentation shows that R1 was transported to Kaiser Emergency Room on multiple occasions for evaluation related to these behaviors. As a result, staff required R1’s family to arrange one-to-one supervision. Additionally, R1’s medications were adjusted in an effort to manage R1’s behaviors. Facility charting notes indicate that R1 began exhibiting concerning behaviors in June 2025. On 07/01/2025, the facility met with R1’s family and primary care physician to address the behaviors. On 07/29/2025, facility staff met with R1’s neurologist regarding the ongoing concerns. On 08/07/2025, the facility met with R1’s power of attorney and responsible party to further address R1’s behaviors. Charting notes also document multiple occasions when R1 was sent to the emergency room due to these behaviors. CONTINUED LIC 809-C Additionally, it was confirmed that the responsible parties for both R2 and R3 were informed of the situation, were aware of their respective interactions with R1, and expressed support and acceptance. The facility informed R1’s responsible party that R1 required continuous one-to-one supervision due to R1’s behaviors. Subsequently, R1’s responsible party elected to remove R1 from the facility. Per California Code of Regulations, Title 22, no deficiencies were observed during this visit. Exit interview was conducted and a copy of this report was provided.