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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019201084
Report Date: 09/07/2021
Date Signed: 09/07/2021 05:04:31 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:
019201084
ADMINISTRATOR:VADNAIS, GERRYFACILITY TYPE:
740
ADDRESS:2400 MARINER SQUARE DRIVETELEPHONE:
(510) 341-5959
CITY:ALAMEDASTATE: CAZIP CODE:
94502
CAPACITY:80CENSUS: 64DATE:
09/07/2021
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
11:10 AM
MET WITH:AVON NGUYENTIME COMPLETED:
02:10 PM
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On 9/7/2021 , Licensing Program Analyst (LPA) L. Ibo arrived unannounced to conduct a pre-licensing inspection due to a change of ownership. LPA met with Nurse Avon Nguyen, Administrator Gerry Vadnais was called to inform the purpose of the visit, Administrator gave permission to LPA to conduct the inspection with Nurse Avon Nguyen.

Facility has an approved fire clearance for 6 bedridden residents on any room on first floor and second floor and 74 non ambulatory residents. Last fire inspection was conducted on August 4,2021. LPA inspected the facility including but not limited to 7 resident rooms common areas, kitchen,activity room, dining and outside areas. Hot water measured at 117.2 degrees Fahrenheit. Fire extinguisher was observed around the common areas of the facility with inspection tags dated January 3rd 2021. There was sufficient supply of perishable and non-perishable foods. First aid kit was complete.

....Continue to LIC809C....
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: 019201084
VISIT DATE: 09/07/2021
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LPA's observed the following during inspection:

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

Component III was waived.

LPA is not recommending facility for license until all deficiencies are cleared. This Pre-Licensing report will be submitted to the Central Application Branch (CAB) for review. Exit interview conducted with Applicant/nurse..

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
LIC809 (FAS) - (06/04)
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