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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079200925
Report Date: 08/02/2021
Date Signed: 08/02/2021 02:43:20 PM

Document Has Been Signed on 08/02/2021 02:43 PM - It Cannot Be Edited

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 CONCORDFACILITY NUMBER:
079200925
ADMINISTRATOR:ANGELES STICKAFACILITY TYPE:
740
ADDRESS:1401 CIVIC COURTTELEPHONE:
(925) 798-4004
CITY:CONCORDSTATE: CAZIP CODE:
94520
CAPACITY: 121CENSUS: 77DATE:
08/02/2021
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
02:15 PM
MET WITH:Angeles Sticka, Executive DirectorTIME COMPLETED:
02:55 PM
NARRATIVE
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On 8/2/2021 at 2:15PM, Licensing Program Analyst (LPA) G. Luk arrived unannounced to conduct a case management inspection due to a change of ownership. LPA met with Executive Director (ED), Angeles Sticka.

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

At 12:00PM, LPA observed S1, S2, S4, S6, and S7 does not have current 1st aid training on file during record review.

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

Exit interview conducted. A copy of this report and appeal rights provided.
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Grace Luk
LICENSING EVALUATOR SIGNATURE: DATE: 08/02/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/02/2021
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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Document Has Been Signed on 08/02/2021 02:43 PM - It Cannot Be Edited


Created By: Grace Luk On 08/02/2021 at 02:21 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

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

FACILITY NAME: OAKMONT OF CONCORD
FACILITY NUMBER: 079200925

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/02/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
08/09/2021
Section Cited
CCR
87411(c)(1)

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Personnel Requirements - General. Staff providing care shall receive appropriate training in first aid from persons qualified by such agencies as the American Red Cross. This requirement is not met as evidence by:
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Executive Director has agreed to obtain 1st aid training for S1, S2, S4, S6, and S7. ED will submit certificate to CCLD by POC date.
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Based on record review, licensee did not comply with the section cited above by not having current 1st aid training for some staff which poses a potenital health and safety risk to the persons in care.
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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 Humpal
LICENSING EVALUATOR NAME:Grace Luk
LICENSING EVALUATOR SIGNATURE:
DATE: 08/02/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/02/2021


LIC809 (FAS) - (06/04)
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