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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079201085
Report Date: 08/02/2021
Date Signed: 08/02/2021 02:42:41 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 CONCORDFACILITY NUMBER:
079201085
ADMINISTRATOR:STICKA, ANGELESFACILITY TYPE:
740
ADDRESS:1401 CIVIC COURTTELEPHONE:
(925) 798-4004
CITY:CONCORDSTATE: CAZIP CODE:
94520
CAPACITY:121CENSUS: 77DATE:
08/02/2021
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Angeles Sticka, Executive DirectorTIME COMPLETED:
02:15 PM
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On 8/2/2021 at 9:30AM, Licensing Program Analyst (LPA) G. Luk arrived unannounced to conduct a Pre-Licensing inspection. LPA met with Executive Director (ED), Angeles Sticka. The facility's fire clearance was approved for 113 non-ambulatory and 8 bedridden residents.

LPA toured facility with ED including but not limited to resident's bedrooms, bathrooms, kitchen, laundry room, activity room, and outdoor area. Resident's rooms were fully furnished and clean. Resident's bathrooms were equipped with grab bars and non-skid mat/material. LPA observed lighting in all rooms. LPA observed facility had a 7-day of non-perishable and 2-day of perishable food supply. Facility has medication carts with locks kept in the med room. Smoke detectors and Carbon Monoxide detectors are interconnected with sprinkler system. First aid kit is complete. LPA measured hot water temperature at 112.8 degrees F in resident's bathroom. Indoor and outdoor passageways were free of obstruction. Fire extinguisher was observed to be full and last serviced on 2/11/2021. Emergency disaster plan was completed.

The following will need to be completed before recommending licensure to Centralized Application Bureau (CAB):

1. LPA observed that S1, S2, S4, S6, S7 did not have current 1st aid training on file.

Licensee/applicant will submit proof of corrections to CCL on/before 8/9/2021.



LPAs conducted Component III with Licensee during inspection. LPA presented Component III Power Point and discussed the regulations embodied in the presentation.

Exit interview conducted and a copy of this report provided.
SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Grace LukTELEPHONE: (510) 286-4201
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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