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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079201083
Report Date: 07/11/2022
Date Signed: 07/11/2022 11:20:13 AM

Document Has Been Signed on 07/11/2022 11:20 AM - 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:MONTECITO OAKMONT SENIOR LIVINGFACILITY NUMBER:
079201083
ADMINISTRATOR:WONG, ELAINEFACILITY TYPE:
740
ADDRESS:4756 CLAYTON ROADTELEPHONE:
(925) 692-5838
CITY:CONCORDSTATE: CAZIP CODE:
94521
CAPACITY: 230CENSUS: 181DATE:
07/11/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
10:18 AM
MET WITH:Elaine Wong, AdministratorTIME COMPLETED:
11:30 AM
NARRATIVE
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On 07/11/22 at 10:18 AM, Licensing Program Analyst (LPA) C. Lin conducted an unannounced case management visit as a result of receiving self-reported incident dated 06/08/22 submitted to CCLD regarding resident sustained injury while was transporting to a designation on the community bus. LPA explained the purpose of the visit with administrator (ADM).

ADM admitted the incident was occurred by a staff member careless. The investigation was determined that the wheelchair strap to the right-side wheel was not properly secured, the buckle fell off when bus driver made a turn, which caused wheelchair to tip over left side resulting resident to fall. Resident was transported to John Muir hospital and diagnosed injury of left shoulder and strain of neck muscle. LPA obtained resident physician's report, care notes, and in-services training record during visit.

Deficiency is cited per Title 22 California Code of Regulations and listed on LIC809 D. Failure to submit proofs of correction (POC) by plan of correction due date and/or any repeat deficiencies within a 12-month period may result in additional civil penalties. Immediately Civil Penalties $500 is assessed today.

Exit interview conducted with ADM. Appeal Rights and a copy of this report provided.

SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Catherine Lin
LICENSING EVALUATOR SIGNATURE: DATE: 07/11/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/11/2022
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 07/11/2022 11:20 AM - It Cannot Be Edited


Created By: Catherine Lin On 07/11/2022 at 10:51 AM
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: MONTECITO OAKMONT SENIOR LIVING
FACILITY NUMBER: 079201083

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/11/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
07/12/2022
Section Cited
HSC
1569.269(a)(10)

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1569.269 Enumerated rights; severability
(a)Residents of residential care facilities for the elderly shall have all of the following rights:
(10)To be free from neglect, financial exploitation, involuntary seclusion, punishment, humiliation, intimidation, and verbal, mental, physical, or sexual abuse.

This requirement is not met as evidenced by…
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Deficiency cleared during visit.

Administrator had retrained staff regarding safety on 6/10/2022 and provided proof of training record to LPA during visit.
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Based on record reviewed and interview, licensee did not comply with the section cited above. Neglet was occurred and resulted resident in injury which poses an immediate health, safety risk to persons in care.
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Immediately Civil Penalties $500 is assessed.

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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:Bennett Fong
LICENSING EVALUATOR NAME:Catherine Lin
LICENSING EVALUATOR SIGNATURE:
DATE: 07/11/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/11/2022


LIC809 (FAS) - (06/04)
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