306005740-12-22-2020-22-AS-KCHN-BWJ7YE-20201221210438

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 306005740
Report Date: 12/21/2020
Date Signed: 12/22/2020 02:05:54 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 ORANGE		FACILITY NUMBER:	306005740
ADMINISTRATOR:	EUSEY, CHARLES		FACILITY TYPE:	740
ADDRESS:	630 THE CITY DRIVE SOUTH		TELEPHONE:	(714) 912-8980
CITY:	ORANGE	STATE: CA	ZIP CODE:	92868
CAPACITY:	155	CENSUS: 84	DATE:	12/21/2020
TYPE OF VISIT:	Prelicensing	UNANNOUNCED	TIME BEGAN:	10:00 AM
MET WITH:	Charles Eusey, ED		TIME COMPLETED:	01:00 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analysts (LPA), Kathrina Chin contacted the facility via FaceTime App to commence a pre-licensing inspection due to COVID-19 and pre-cautionary measures. LPA identified herself and discussed the purpose of the visit and spoke to Charles Eusey, Executive Director. This pre-licensing visit is due to a change of ownership. The inspection was as follows: The main structure is a three story building which includes 104 resident units in total. The entire community was designed to accommodate 155 non-ambulatory residents. There is a Memory Care unit on the first floor and has a capacity for 38 residents. There are three delayed egress exits on the first floor. A fire clearance was granted on December 3, 2020 for 155 non-ambulatory residents of which 8 may be bedridden on the first floor only. This facility has submitted a hospice waiver request for 16 residents. LPA toured the entire community, interior and exterior, including a sampling of resident bedroom units. Hot water were tested in 10 apartment units and observed to be between 112-121 degrees Fahrenheit. Fire extinguishers were mounted and charged. Smoke detectors were centrally wired throughout and have been checked by the fire department. The facility has dual smoke detectors and carbon monoxide detectors throughout the building. There was one E-Vacs chairs near each of the three stairwells at the facility. There was two locked medication rooms on the first floor( one in memory care and one is Assisted Living). Both medicaton rooms store first aid kits. There is a large storage of toxins and cleaning equipment in the basement. An emergency call system was in place in each apartment unit and several were tested. The kitchen area was checked. There were emergency food supplies and water. LPA observed activity calendars, theft and loss policy, residents rights, admission agreement, resident rights and emergency plans were posted including the Ombudsman and Let Us Know poster. The Memory Care unit has their own activity room/ living room area and dining area. LPA reviewed the outdoor area and observed a covered patio structure and outdoor furniture in the memory care and Assisted Living. (Continued on LIC 809C)

SUPERVISOR'S NAME: Sheila Santos	TELEPHONE: (714) 703-2838
LICENSING EVALUATOR NAME: Kathrina Chin	TELEPHONE: (714) 703-2840
LICENSING EVALUATOR SIGNATURE:	DATE: 12/21/2020

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/21/2020

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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

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 ORANGE	FACILITY NUMBER: 306005740
	VISIT DATE: 12/21/2020

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(Continued)

An Abbreviated Component III was conducted with Charles Eusey, ED today.

It appears that this facility meets the requirements for licensure. Both the license and the hospice waiver will be granted upon final review and approval from the Central Applications Bureau.
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An exit teleconference was conducted with Charles Eusey, ED and LPA Chin discussed and read this report. A copy of this report will be provided via email.

SUPERVISOR'S NAME: Sheila Santos	TELEPHONE: (714) 703-2838
LICENSING EVALUATOR NAME: Kathrina Chin	TELEPHONE: (714) 703-2840
LICENSING EVALUATOR SIGNATURE:	DATE: 12/21/2020

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/21/2020

LIC809 (FAS) - (06/04)

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