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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079201085
Report Date: 01/19/2023
Date Signed: 01/19/2023 01:12:54 PM


Document Has Been Signed on 01/19/2023 01:12 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:
079201085
ADMINISTRATOR:NGUYEN, AVONFACILITY TYPE:
740
ADDRESS:1401 CIVIC COURTTELEPHONE:
(925) 798-4004
CITY:CONCORDSTATE: CAZIP CODE:
94520
CAPACITY:121CENSUS: 85DATE:
01/19/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
12:00 PM
MET WITH:Susana Chavez, Memory Care DirectorTIME COMPLETED:
01:25 PM
NARRATIVE
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On 1/19/2023 starting at 12:00 PM, Licensing Program Analysts (LPAs) L. Francisco and P. Watson conducted a Case Management visit while at the facility for complaint # (CN# 15-AS-20211020151456). LPAs met with Memory Care Director, Susana Chavez.

During a tour of facility, LPAs observed oxygen tanks (1 big oxygen tank and 5 small oxygen tanks) next to the bedside table in R3's apartment. The oxygen tanks were not secured in a stand or to the wall.

The following deficiencies were observed (see LIC 809D) and cited from the California Code of Regulations, Title 22. Failure to correct deficiencies by POC date may result in additional Civil Penalties.

Exit interview conducted. Appeal Rights and a copy of this report provided to Memory Care Director.
SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Lizette FranciscoTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:
DATE: 01/19/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/19/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2


Document Has Been Signed on 01/19/2023 01:12 PM - It Cannot Be Edited

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 CONCORD
FACILITY NUMBER: 079201085

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/19/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
01/26/2023
Section Cited

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87618(b)(3)(E) OXYGEN ADMINISTRATION - GAS AND LIQUID
(b) In addition to Section 87611(b)..(3) Ensuring that the use of oxygen equipment meets the following requirements: (E) Oxygen tanks that are not portable shall be secured in a stand or to the wall.
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By POC date, Administrator agrees to remove oxygen tanks from R3's apartment and have it picked up by the company and submit self certification letter to CCLD. In addition, Administrator will review regulation and provide in-service training to staff and submit a copy of training with staff signatures.
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This requirement is not met as evidenced by: Based on observation, the Licensee did not comply with the regulation above. LPAs observed oxygen tanks in R3's apartment were not secured to a stand or a wall which poses a potential health and safety risk to 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 HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Lizette FranciscoTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:
DATE: 01/19/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/19/2023
LIC809 (FAS) - (06/04)
Page: 2 of 2