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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079201083
Report Date: 11/28/2022
Date Signed: 11/28/2022 05:21:19 PM


Document Has Been Signed on 11/28/2022 05:21 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
E BAY DELTA AC/SC, 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: 182DATE:
11/28/2022
TYPE OF VISIT:Post LicensingUNANNOUNCEDTIME BEGAN:
03:20 PM
MET WITH:Maria Tejano, Health Services DirectorTIME COMPLETED:
05:30 PM
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On 11/23/2022 at 3:20 PM Licensing Program Analyst (LPA) P. Watson arrived unannounced and conducted a Post Licensing inspection. LPA was greeted by Michaela Olson, Marking Director and Maria Tejano, Health Services Director.

The tour included but not limited to the residents bedrooms/apartments, shared bathrooms, dining rooms, common living areas, and kitchen. There is sufficient lighting around the facility. Residents rooms/apartments are equipped with the proper furniture and lighting. The kitchen was observed cleaned and within compliance. LPA observed an adequate amount of at least one week nonperishable and two day of perishable foods Bathrooms were equipped with grab bars and emergency call button. Passageways and hallways are clear of obstruction. Facility has two (2) med-tech rooms. Fire extinguishers were last inspected on 11/14/2022. First aid kit was complete with manual. Carbon monoxide and smoke detectors were interconnected and observed during visit. The facility’s fire clearance was approved for 230 non-ambulatory, which 6 may be bedridden. Hospice waiver for 15.

Facility temperature is maintained at 76 degrees Fahrenheit. Hot water temperature measures degrees 113 Fahrenheit in one of the bathrooms. Facilities hot water is maintained between 108 - 114 Fahrenheit.

Staff records were reviewed showing that all have criminal record clearances and associated with the facility. Residents’ records were reviewed and found to be organized and filed properly.

Exit interview conducted and a copy of this report provided.
SUPERVISOR'S NAME: Yvonne Flores-LariosTELEPHONE: (510) 725-7926
LICENSING EVALUATOR NAME: Paris WatsonTELEPHONE: (510) 622-2625
LICENSING EVALUATOR SIGNATURE:
DATE: 11/28/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/28/2022
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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