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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 216804010
Report Date: 06/17/2022
Date Signed: 06/17/2022 10:39:40 AM


Document Has Been Signed on 06/17/2022 10:39 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, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405



FACILITY NAME:OAKMONT OF SAN RAFAELFACILITY NUMBER:
216804010
ADMINISTRATOR:DOWELL, CAROLFACILITY TYPE:
740
ADDRESS:1 LAS GALINAS AVETELEPHONE:
(628) 336-1400
CITY:SAN RAFAELSTATE: CAZIP CODE:
94903
CAPACITY:126CENSUS: 55DATE:
06/17/2022
TYPE OF VISIT:Post LicensingUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Administrator, Carol DowellTIME COMPLETED:
10:55 AM
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Licensing Program Analyst (LPA), Farhaan Sarangi arrived unannounced at Oakmont of San Rafael for the purpose of conducting a Post Licensing Inspection. LPA was greeted at the door by Administrator, Carol Dowell and was granted access into the facility.

LPA toured the facility with Administrator, Carol Dowell. LPA observed the facility to be clean and at a comfortable temperature with all exits free from obstruction. Perishable and Non-Perishable foods were observed in the kitchen fridge and freezer that was stored as per regulation. LPA observed small couches and a kitchen prep area in the Memory Care Unit. LPA observed the Memory Care unit on the first floor and one unit room that had a water temperature of 114.6 degrees, showers are equipped with Non-slip floors and handrails by shower and toilets for residents use. LPA also observed the egress door in the Memory Care unit that is properly operational and functioning at this time. While touring, LPA observed the Memory Care Unit dining room with 8 tables and chairs. LPAs observed three emergency water containers that are stored in the garage. LPA observed the movie theater with chairs and a popcorn machine which is also on the garage level. LPA observed the outdoor seating area with two tables and chairs in the Memory Care Unit. LPA observed the locked Memory Care Unit Medication Room along with the locked Laundry room and Housekeeping room that keeps the hazardous toxins locked and inaccessible to residents in care. LPA toured the second floor and observed 109.4 degrees water temperature in a bedroom unit and Non-slip floors and handrails by shower and toilets for residents use. All fire extinguishers were last serviced on April 2022. LPA observed the activity room with 6 small tables and 1 big table by the residential kitchen and water temperature was at 114.6 degrees. LPA observed the dining room also on the third floor with 12 tables and an outdoor dining patio. LPA observed the kitchen where food is served. LPA observed the third floor that was equipped with a lounge/bar. Lounge/bar is locked outside of operating hours making it inaccessible to residents in care. LPAs observed the exercise room and a salon where residents can have access to those amenities. Exercise room is left open at all times and the salon is observed to be locked during non-operating hours. (Report continued on LIC 809C)
SUPERVISOR'S NAME: Hope DeBenedettiTELEPHONE: (707) 588-5029
LICENSING EVALUATOR NAME: Farhaan SarangiTELEPHONE: 707-588-5034
LICENSING EVALUATOR SIGNATURE:
DATE: 06/17/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/17/2022
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME: OAKMONT OF SAN RAFAEL
FACILITY NUMBER: 216804010
VISIT DATE: 06/17/2022
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In addition, LPA advised facility to contact County Public Health and Community Care Licensing immediately if symptoms or COVID-19 + in the facility. Facility staff have been N95 Fit tested. LPAs observed the storage for Emergency supplies. LPA advised Administrator to bring the portable generator back from the sister facility.

No deficiencies observed or cited during today's Post Licensing Inspection. Exit interview was conducted and a copy of this report was signed and emailed to the Administrator due to printing issues.
SUPERVISOR'S NAME: Hope DeBenedettiTELEPHONE: (707) 588-5029
LICENSING EVALUATOR NAME: Farhaan SarangiTELEPHONE: 707-588-5034
LICENSING EVALUATOR SIGNATURE:

DATE: 06/17/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/17/2022
LIC809 (FAS) - (06/04)
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