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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019200889
Report Date: 09/07/2021
Date Signed: 09/07/2021 05:03:43 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME:OAKMONT OF MARINER POINTFACILITY NUMBER:
019200889
ADMINISTRATOR:AVON NGUYENFACILITY TYPE:
740
ADDRESS:2400 MARINER SQUARE DRIVETELEPHONE:
(510) 347-5959
CITY:ALAMEDASTATE: CAZIP CODE:
94501
CAPACITY:80CENSUS: 64DATE:
09/07/2021
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
02:10 PM
MET WITH:AVON NGUYENTIME COMPLETED:
05:25 PM
NARRATIVE
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On 9/7/2021, Licensing Program Analyst (LPA) L. Ibo arrived unannounced to conduct a case management inspection due to a change of ownership. LPA met with nurse Avon Nguyen, Administrator for Gerry Vadnais was called to inform the purpose of the visit, Administrator gave permission to LPA to conduct the inspection with nurse Avon Nguyen.

During Pre-licensing Inspection, LPA observed the following deficiencies:

At 11:46 AM on room 317, R1’s over the counter medication was observed unlocked and accessible to R1. LPA confirmed via records review that facility is managing the medication of R1.

At 11:54 AM on room 227 medication was observed on R2’s bathroom which was accessible to resident in care.

At 11:57 AM on room 229 LPA observed poisonous disinfectant spray was found unlocked which was accessible to R3 or to resident in care.

At 12:09 PM on room 106, LPA observed poisonous disinfectant was found unlocked which was accessible to R4 or to resident in care.

The deficiencies were observed (see LIC 809D) and cited from the California Code of Regulation, Title 22. Failure to correct the deficiencies may result in civil penalties.

Exit interview conducted with Avon Nguyen . A copy of this report and appeal rights was provided.
SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Leslie IboTELEPHONE: 510-286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 09/07/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/07/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC809 (FAS) - (06/04)
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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: OAKMONT OF MARINER POINT
FACILITY NUMBER: 019200889
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/07/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
09/07/2021
Section Cited

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87309 Storage Space (b) Medicines which are centrally stored shall be stored as specified in Section 87465 and separately from other items specified in (a) above.

This requirement is not met as evidence by:

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Based on observation, the licensee did not comply with the section cited above, R1’s medication was observed unlocked and accessible to R1 which posed immediate health and safety risks to person in care.
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Type A
09/07/2021
Section Cited

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87705(f)(2) Care of Persons with Dementia
The following shall be stored inaccessible to residents with dementia:Over-the-counter medication, nutritional supplements or vitamins..toxic substances..

This requirement was not met as evidenced by
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Based on LPA observation, Licensee failed to maintain over the counter medication. LPA observed unlocked medications in R2's room R3 & R4's room was observed to have toxic substances which poses an immediate health and safety risk to residents in care.
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Executive Director will review regulation and conduct in-service training with staff and email a copy of training agenda with staff signatures to CCL by 9/24/2021.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Leslie IboTELEPHONE: 510-286-4201
LICENSING EVALUATOR SIGNATURE:
DATE: 09/07/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/07/2021
LIC809 (FAS) - (06/04)
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