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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005740
Report Date: 08/24/2023
Date Signed: 09/21/2023 12:30:33 PM


Document Has Been Signed on 09/21/2023 12:30 PM - It Cannot Be Edited

Document is an Amendment of Original Document on 09/20/2023 08:55 AM

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

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This is an amended report.

This unannounced Case Management – Incident inspection is being conducted by Licensing Program Analyst (LPA) Sean Haddad for the purpose of following up on self-reported incident reports received in the Orange County Regional Office (OCRO) on 08/16/23 regarding an incident of rough handling resulting in injuries involving Staff #1 (S1), Resident #1 (R1) and Resident #2 (R2). LPA met with Business Office Director (BOD) Jasbir Govender and discussed the purpose of the inspection. Administrator (AD) Anna Pastores arrived during the inspection.

During today’s inspection, LPA and AD toured the facility. LPA observed all sharps, toxins, and medications were properly stored, and observed no health and safety issues. LPA conducted health and safety checks on R1 and R2, conducted interviews, and observed them to be in good spirits and observed no health and safety issues. LPA requested and reviewed copies of the resident roster, staff roster, S1’s staff file, and resident files for R1 and R2.

Facility representative was advised that at this time further investigation is required. An exit interview was conducted and a copy of this report was discussed with and provided to facility representative.
SUPERVISOR'S NAME: Armando J LuceroTELEPHONE: (714) 703-2840
LICENSING EVALUATOR NAME: Sean HaddadTELEPHONE: (714) 335-7094
LICENSING EVALUATOR SIGNATURE:
DATE: 09/21/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/21/2023
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 3


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: 08/24/2023
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This is an amended report.
SUPERVISOR'S NAME: Armando J LuceroTELEPHONE: (714) 703-2840
LICENSING EVALUATOR NAME: Sean HaddadTELEPHONE: (714) 335-7094
LICENSING EVALUATOR SIGNATURE:

DATE: 09/21/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/21/2023
LIC809 (FAS) - (06/04)
Page: 2 of 3
Document is an Amendment of Original Document on 09/20/2023 08:56 AM

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

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/24/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
08/31/2023
Section Cited
CCR
87464(f)(1)

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87464 Basic Services. (f) Basic services shall at a minimum include: (1) Care and supervision as defined in Section 87101(c)(3) and Health and Safety Code section 1569.2(c). This requirement was not met as evidenced by:
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Licensee immediately suspended and terminated S1. Licensee stated they will retrain all staff on proper handling of residents and reporting abuse and submit proof to LPA by POC due date.
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Based on interview and documents, the licensee did not ensure R1 and R2 received proper care and supervision when they were handled roughly, which posed a potential health and safety risk to persons in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Armando J LuceroTELEPHONE: (714) 703-2840
LICENSING EVALUATOR NAME: Sean HaddadTELEPHONE: (714) 335-7094
LICENSING EVALUATOR SIGNATURE:
DATE: 08/24/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/24/2023
LIC809 (FAS) - (06/04)
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