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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197610184
Report Date: 05/24/2022
Date Signed: 05/24/2022 11:01:32 AM


Document Has Been Signed on 05/24/2022 11:01 AM - 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, 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: 93DATE:
05/24/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
09:45 AM
MET WITH:Tom Park, Executive DirectorTIME COMPLETED:
11:20 AM
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Licensing Program Analyst (LPA) Angela Panushkina met with Tom Park, Executive Director, at 10:00am for a case management visit. The purpose of the case management visit is to confirm removal of staff.

Entrance interview conducted.

At 10:00am LPA reviewed confirmation of removal form and requested LIC500 Personnel Report. Staff #1 is not indicated on the LIC500. LPA conducted a physical plant tour at 10:30am and no health and safety issues were observed. Staff #1 was initially hired as a MedTech. However, as of 04/25/22 the staff is no longer employed with the facility and has not returned.

Based on evidence obtained during today’s visit, the LPA has verified the individual is not present, employed or residing at the facility. LPA advised the Administrator to disassociate the individual from their roster. Contact Caregiver Background Check Bureau at 888-422-5669.

Verification of removal is complete.

Exit interview conducted and copy of this report was provided to the Executive Director.
SUPERVISOR'S NAME: Nichelle GillyardTELEPHONE: (818) 596-4341
LICENSING EVALUATOR NAME: Angela PanushkinaTELEPHONE: 747-230-3364
LICENSING EVALUATOR SIGNATURE:
DATE: 05/24/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/24/2022
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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