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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 092700750
Report Date: 06/03/2024
Date Signed: 06/03/2024 01:07:54 PM


Document Has Been Signed on 06/03/2024 01:07 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
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827



FACILITY NAME:OAKMONT OF EL DORADO HILLSFACILITY NUMBER:
092700750
ADMINISTRATOR:GRAVELYN, LYDIAFACILITY TYPE:
740
ADDRESS:2020 TOWN CENTER WEST WAYTELEPHONE:
(916) 467-8330
CITY:EL DORADO HILLSSTATE: CAZIP CODE:
95762
CAPACITY:129CENSUS: 87DATE:
06/03/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
12:30 PM
MET WITH:Health Services Director Stephanie WilliamsTIME COMPLETED:
01:20 PM
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Licensing Program Analyst (LPA) Lavinia Muscan arrived at the facility unannounced on 6/3/24 to do a case management visit. LPA met with Health Services Director Stephanie Williams and explained the purpose of the visit.

Department followed up on an Incident report that happened on 5/18/24. Incident report sent into the department on 5/21/24. R1 was having dinner in the dining room when R1 appeared to be choking. Staff was called and performed the Heimlich maneuver, then chest compressions. Additionally, 911 was called. R1 passed 5/18/24.

LPA received all documents requested.

At this time, this case in under review and department will follow up as needed.

No citations were issued per Title 22 Regulations.

Exit interview conducted and copy of the report left at facility.
SUPERVISOR'S NAME: Laura MunozTELEPHONE: (916) 263-4743
LICENSING EVALUATOR NAME: Lavinia MuscanTELEPHONE: 916-263-4700
LICENSING EVALUATOR SIGNATURE:
DATE: 06/03/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/03/2024
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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