<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 315002798
Report Date: 05/04/2022
Date Signed: 05/04/2022 02:33:31 PM


Document Has Been Signed on 05/04/2022 02:33 PM - It Cannot Be Edited

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 ROSEVILLEFACILITY NUMBER:
315002798
ADMINISTRATOR:ERVIN, TERENCEFACILITY TYPE:
740
ADDRESS:1101 SECRET RAVINE PARKWAYTELEPHONE:
(916) 771-6700
CITY:ROSEVILLESTATE: CAZIP CODE:
95661
CAPACITY:120CENSUS: 77DATE:
05/04/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
01:39 PM
MET WITH:Executive Director Angelique Doyle and Health Service Director Lori Gales TIME COMPLETED:
02:40 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
On 05/04/2022, Licensing Program Analyst (LPA) Sarena Keosavang arrived at the facility unannounced to conduct Case Management visit and met with Health Service Director, Lori Gales. LPA wore a Surgical mask and were screen by facility staff prior to entering the facility.

LPA explained the purpose of the visit was to follow-up on two theft unusual incident/injury report that was sent to Community Care Licensing (CCL) on 03/24/2022. First incident report indicates resident (R1) wedding ring and chain went missing. Second incident indicates R2 reported to the facility fraudulent activity on bank account. Both incident occurred on 03/24/2022.

LPA toured the facility together with Health Service Director. Executive Director (ED), Angelique Doyle, arrived at a later time. LPA interviewed ED regarding the report. ED stated the facility conducted an internal investigation and reported theft to Roseville Police Department. Police Report Number 2022-15099.

At this time, deficiencies are not being cited.

An exit interview conducted. A copy of this report was left at the facility.
SUPERVISOR'S NAME: Anthony PerezTELEPHONE: (323) 485-4915
LICENSING EVALUATOR NAME: Sarena KeosavangTELEPHONE: (209) 202-9552
LICENSING EVALUATOR SIGNATURE:
DATE: 05/04/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/04/2022
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 1