315002798-7-27-2021-25-AS-PSIH-C5BVMT-20210727163403

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 315002798
Report Date: 07/27/2021
Date Signed: 07/27/2021 04:34:09 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 520 COHASSET RD., STE. 170
CHICO, CA 95926

FACILITY NAME:	OAKMONT OF ROSEVILLE		FACILITY NUMBER:	315002798
ADMINISTRATOR:	ERVIN, TERENCE		FACILITY TYPE:	740
ADDRESS:	1101 SECRET RAVINE PARKWAY		TELEPHONE:	(916) 771-6700
CITY:	ROSEVILLE	STATE: CA	ZIP CODE:	95661
CAPACITY:	120	CENSUS: 79	DATE:	07/27/2021
TYPE OF VISIT:	Prelicensing	UNANNOUNCED	TIME BEGAN:	02:40 PM
MET WITH:	Terence Ervin, Executive Director		TIME COMPLETED:	04:45 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 Analyst (LPA) Praveen Singh arrived to conduct an announced Pre-Licensing inspection. LPA met with Executive Director Terence Ervin (ED) and Interim Executive Director Angelique Doyle and explained the purpose of the visit. Prior to initiating the Pre-Licensing inspection, LPA completed required COVID-19 testing protocols, and a daily self-screening questionnaire for symptoms of COVID-19 infection to affirm no COVID-19 related symptoms; contacted Facility Representative and completed a facility risk assessment. LPA ensured she applied hand sanitizer before entering the facility and the following Personal Protective Equipment (PPE) was worn: surgical mask. Additionally, LPA was screened by Ariana Gales. This facility currently has 79 residents and is operating under license number 312700602. This Pre-Licensing is relative to facility's change of ownership. The facility includes a separate unit called "Traditions" designated for memory care residents. This facility consists of two floors and LPA toured the facility inside and out, including but not limited to the kitchen, dining rooms, common living areas, activity rooms, a random sampling of resident bedrooms and bathrooms, centrally stored medication rooms, Traditions unit, and outdoor areas. LPA observed bathrooms contained grab bars and non-skid mats. Hot water temperature in resident bathroom measured at 105 degrees F. LPA observed a sufficient supply of dishes and utensils as well as a sufficient 7-day supply of non-perishable and 2-day supply of perishable foods in the kitchen. Large Ombudsman, Bill of Rights, and If You See Something... posters were posted on the walls outside the Traditions unit as well as the common area for assisted living residents. [See LIC809-C for Continued Report]

SUPERVISOR'S NAME: Laura Munoz	TELEPHONE: (916) 236-4743
LICENSING EVALUATOR NAME: Praveen Singh	TELEPHONE: (916) 263-4700
LICENSING EVALUATOR SIGNATURE:	DATE: 07/27/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/27/2021

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, 520 COHASSET RD., STE. 170
CHICO, CA 95926

FACILITY NAME: OAKMONT OF ROSEVILLE	FACILITY NUMBER: 315002798
	VISIT DATE: 07/27/2021

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Facility Fire Clearance was approved on May 24, 2021 for 110 non-ambulatory and 10 bedridden residents. LPA observed the emergency water and food supply as well as multiple first aid kits. Fire extinguishers were last serviced on July 8, 2021. LPA observed a Disaster Manual binder at the facility and resident files, staff files, centrally stored medications logs, and medication administration records were maintained and organized.

A component III has been waived. LPA observed that facility is ready to be licensed. This report will be submitted to the Central Applications Unit (CAU) and a final review of the application will be conducted. This facility is not yet licensed, and is subject to final approval by CAU. Additional requirements may still be required.

Exit interview conducted and a copy of the report provided.

SUPERVISOR'S NAME: Laura Munoz	TELEPHONE: (916) 236-4743
LICENSING EVALUATOR NAME: Praveen Singh	TELEPHONE: (916) 263-4700
LICENSING EVALUATOR SIGNATURE:	DATE: 07/27/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/27/2021

LIC809 (FAS) - (06/04)

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