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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005795
Report Date: 01/27/2022
Date Signed: 01/27/2022 05:00:25 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 FULLERTONFACILITY NUMBER:
306005795
ADMINISTRATOR:KNEEDY-CAYEM, KARAFACILITY TYPE:
740
ADDRESS:433 WEST BASTANCHURY ROADTELEPHONE:
(714) 869-1940
CITY:FULLERTONSTATE: CAZIP CODE:
92835
CAPACITY:152CENSUS: 98DATE:
01/27/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
03:00 PM
MET WITH:Allan Perez, Resident Care DirectorTIME COMPLETED:
05:00 PM
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Licensing Program Analyst (LPA), Kathrina Chin conducted a case management- incident as a follow up to an incident report. LPA Chin identified herself and met with Allan Perez, Resident Care Director regarding a self-reported incident which occurred on January 19, 2022 and a SOC 341 was submitted to the licensing office on January 20, 2022. LPA also spoke to Kara Kneedy-Cayem, Executive Director over the telephone and discussed the purpose of the visit.

On 1/19/2022, two female staff members went to assist R1 to change her incontinent briefs. R1 went out of her room to the hallway. Due to her COVID positive staff, the LVN re-directed her back to her room to quarantine. R1 stated, " I've just been molested." The facility reported it to the police department and Ombudsman Office. R1 resides in the Memory Care Unit.

Today, LPA interviewed R1 along with Alma Lopez, Activity Coordinator and Allan Perez, Resident Care Coordinator. R1 stated that it did not happen in this building, facility or her room and it happened two days ago. R1 reported that it happened somewhere else. She said that she could not recall what happened.

No deficiency cited this review.

An exit interview was conducted and a copy of this report was provided to Allan Perez, Resident Care Director.
SUPERVISOR'S NAME: Sheila SantosTELEPHONE: (714) 703-2838
LICENSING EVALUATOR NAME: Kathrina ChinTELEPHONE: (714) 703-2840
LICENSING EVALUATOR SIGNATURE:

DATE: 01/27/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/27/2022
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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