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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005673
Report Date: 09/23/2020
Date Signed: 09/23/2020 04:54:47 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME:OAKMONT OF HUNTINGTON BEACHFACILITY NUMBER:
306005673
ADMINISTRATOR:AYALA, ROSAFACILITY TYPE:
740
ADDRESS:18922 DELAWARE STREETTELEPHONE:
(657) 204-4600
CITY:HUNTINGTONSTATE: CAZIP CODE:
92648
CAPACITY:111CENSUS: 76DATE:
09/23/2020
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
03:37 PM
MET WITH:Administrator Rosa AyalaTIME COMPLETED:
04:30 PM
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Licensing Program Analyst (LPA) Jenifer Tirre made a virtual unannounced tele-inspection visit via Face Time due to COVID-19 Pre-cautions and measures. The purpose of the tele-inspection visit is to follow up on a Confirmation of Removal of a Exclusion Decision Order. LPA met with Administrator (AD) Rosa Ayala and stated the purpose of the visit and a virtual tour of the facility was conducted.

On 9/23/20, LPA received a copy of Exclusion Decision and Order on the removal regarding Staff 1 (S1), AD was asked to send over updated Facility Roster and current staffing schedule to confirm removal. LPA toured facility and viewed Common dining areas, outside patios, concierge desk, Memory Care Unit, Assisted Living, Kitchen, Bistro, Med Tech room and resident hallways. LPA spoke to 11 staff Members and verified the individual was not present at the facility.

An exit interview was conducted via Face Time.
SUPERVISOR'S NAME: Alisa OrtizTELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Jenifer TirreTELEPHONE: (714) 703-2840
LICENSING EVALUATOR SIGNATURE:

DATE: 09/23/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/23/2020
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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