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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 107209036
Report Date: 12/17/2021
Date Signed: 12/17/2021 12:54:49 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1314 E SHAW AVE
FRESNO, CA 93710
FACILITY NAME:OAKMONT OF NORTH FRESNOFACILITY NUMBER:
107209036
ADMINISTRATOR:GUSTIN, PATRICIAFACILITY TYPE:
740
ADDRESS:5605 N GATES AVETELEPHONE:
(559) 277-5959
CITY:FRESNOSTATE: CAZIP CODE:
93722
CAPACITY:122CENSUS: 71DATE:
12/17/2021
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
12:23 PM
MET WITH:Anjeanette FrancoTIME COMPLETED:
01:30 PM
NARRATIVE
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Licensing Program Analyst (LPA) Katie Brown arrived unannounced at the facility to conduct a Case Management visit. LPA met with and explained the purpose of the visit with Health Services Director (HSD) Anjeanette Franco. Administrator Heidi Setty arrived shortly after.

The purpose of the Case Management visit is to follow up on Special Incident Reports (SIR) submitted to CCLD on 10/15/21 and 11/5/21. The SIRs received were not submitted to the licensing agency within the required seven days following the occurrence.








See LIC809-D for Deficiency


A copy of this report and Appeal Rights were provided and an exit interview was conducted with Administrator.
SUPERVISOR'S NAME: Sergiy PidgirnyTELEPHONE: (559) 650-7923
LICENSING EVALUATOR NAME: Katie BrownTELEPHONE: (559) 243-8080
LICENSING EVALUATOR SIGNATURE:

DATE: 12/17/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/17/2021
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1314 E SHAW AVE
FRESNO, CA 93710

FACILITY NAME: OAKMONT OF NORTH FRESNO
FACILITY NUMBER: 107209036
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/17/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
12/29/2022
Section Cited

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87211 Reporting Requirements
(a) Each licensee shall furnish to the licensing agency such reports as the Department may require, including, but not limited to, the following:
(1) A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence of any of the events specified in (A) through (D) below. This report shall include the resident's name, age, sex and date of admission; date and nature of event; attending physician's name, findings, and treatment, if any; and disposition of the case.

The requirement was not met as evidenced by
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Licensee did not submit complete Special Incident Reports to to CCLD within 7 days. Incident dates include 11/12/21, 11/13/21, 11/15/21, 11/28/21 and 9/14/21.

This poses a potential health & 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: Sergiy PidgirnyTELEPHONE: (559) 650-7923
LICENSING EVALUATOR NAME: Katie BrownTELEPHONE: (559) 243-8080
LICENSING EVALUATOR SIGNATURE:
DATE: 12/17/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/17/2021
LIC809 (FAS) - (06/04)
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