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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197610184
Report Date: 09/23/2021
Date Signed: 09/23/2021 01:17:46 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME:OAKMONT OF SANTA CLARITAFACILITY NUMBER:
197610184
ADMINISTRATOR:PARK, TOMFACILITY TYPE:
740
ADDRESS:28650 NEWHALL RANCH ROADTELEPHONE:
(661) 295-2025
CITY:SANTA CLARITASTATE: CAZIP CODE:
91355
CAPACITY:121CENSUS: 91DATE:
09/23/2021
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Tom Park, Executive DirectorTIME COMPLETED:
01:40 PM
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At 10:00am Licensing Program Analyst (LPA), Angela Panushkina conducted an announced Pre-Licensing visit to the above facility. LPA was greeted by Nora Yousri, the front desk receptionist, who was informed the reason of the visit. At approximately, 10:05am LPA met with the Executive Director, Tom Park. This is a change of ownership application from (Facility #197609905) to (Facility #197610184).

At the time of this visit LPA observed residents present in the facility. All residents appear to be clean and groomed. The facility Fire Clearance dated 07/21/2021 was received for 121 non-ambulatory of which (8) may be bedridden. There are currently (5) bedridden residents. There is a hospice waiver for (12), and during today’s visit, there are only (5) residents on hospice. Today’s site visit consisted of LPA touring the physical plant inside and outside and observed the following:

The facility is a large 2 story building with memory care unit. In the main entrance of the building there is a cafe that is a self-serving refreshment and snack area with seating. The main living room has seating and a grand piano for entertainment. There is a reading room and private dining area for family or visitors to use.



At approximately, 10:30am LPA conducted and inspected facility for fire safety, personal accommodations, food service, and medication procedures and records with Executive Director. The bathrooms were checked for the resident’s private room and the public area and were observed to have grab bars and non-skid showers installed. Water temperature was measured between 114.8-118.2°F in various rooms. Resident rooms had Licensing requirements of bedding, linen, lightening, and observed to be appropriately furnished. The facility's emergency signal system is by Philips Life Line System, which is monitored by a pager carried by staff and is also registered on a central computer located at the front desk. Each resident can activate the system alert buttons, located in the bathroom, by bed and all stairways.

Continue on LIC809-C
SUPERVISOR'S NAME: Nichelle GillyardTELEPHONE: (818) 596-4341
LICENSING EVALUATOR NAME: Angela PanushkinaTELEPHONE: 747-230-3364
LICENSING EVALUATOR SIGNATURE:

DATE: 09/23/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/23/2021
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
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME: OAKMONT OF SANTA CLARITA
FACILITY NUMBER: 197610184
VISIT DATE: 09/23/2021
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All assisted living residents are encouraged to wear alert alarms. The first floor has a memory care unit called "Traditions". This unit has a delayed egress system which is set for 15 seconds. The unit has a dining area and kitchenette for which residents will be served hot food, prepared by the main kitchen and delivered to the unit. It has its own courtyard that is fenced and has emergency exit into the main courtyard with delayed egress. There is no swimming pool or spa on premises.

Facility has a main courtyard for the assisted living residents. At approximately, 11:55am LPA observed appropriate outdoor furniture, with a covered shaded area for residents. There is a dining room and commercial kitchen located on the first floor which LPA inspected around 11:00am and was in compliance. LPA observed enough sufficient supply of 2 days perishable foods and one week of non-perishable foods on premises, with an extra storage unit for emergency food and water. There are laundry areas available for residents. There are storage rooms, ground level parking, beauty salon, media room, fitness room, massage and medication rooms on the first floor.

Medications are kept and stored in a locked room and inaccessible to residents in care. The first aid kit is readily available.

Fire extinguishers were observed throughout the facility (hallway, laundry area, kitchen, etc.), fully charged and were last serviced on 01/18/21. Smoke detectors/carbon monoxide are hard wire and tested yearly by the local Fire Department. LPA obtained a copy of the report.


Component III was conducted with the administrator.

Facility is in compliance with Title 22 Regulations at this time. This report will be forwarded to the Centralized Application Bureau (CAB) and be notified by the CAB Analyst when your license has been approved.

Exit interview was conducted with Executive Director, Tom Park and a copy of this report was provided.
SUPERVISOR'S NAME: Nichelle GillyardTELEPHONE: (818) 596-4341
LICENSING EVALUATOR NAME: Angela PanushkinaTELEPHONE: 747-230-3364
LICENSING EVALUATOR SIGNATURE:

DATE: 09/23/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/23/2021
LIC809 (FAS) - (06/04)
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