315002798-7-20-2022-25-AS-JWIS-CGGPM9-20220719112557

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 315002798
Report Date: 07/19/2022
Date Signed: 07/20/2022 02:42:29 PM

Document Has Been Signed on 07/20/2022 02:42 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 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: 81	DATE:	07/19/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:45 AM
MET WITH:	Angelique Doyle- Executive Director		TIME COMPLETED:	11:30 AM

NARRATIVE

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On 07/19/2022 Licensing Program Analysts (LPAs) Keosavang & Williams arrived at the facility unannounced to conduct a Required-1 Year Inspection utilizing the infection control domain, LPAs met with Angelique Doyle, Executive Director and explained the purpose of the visit. Prior to initiating the annual 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. LPA ensured they applied hand sanitizer before entering the facility and the following Personal Protective Equipment (PPE) was worn: N95 Masks. Additional LPAs was screen at the front door before entering the facility.

LPA Keosavang & Williams and Ms Doyle toured facility together to ensure health and safety of residents in care. Areas toured include but are not limited to common areas, ten (10) resident bedrooms, twelve (12) bathrooms, kitchen, salon and outdoor courtyard area. LPAs Keosavang, Williams and Ms Doyle completed the infection control domain.

During the inspection, LPAs observed kitchen staff preparing food without wearing a mask. LPAs toured the salon area with Executive Director and observed a contracted salon worker giving a manicure to a resident while not wearing a mask. This is of significant concern considering the facility is a COVID-19 positive facility which poses an immediate threat to residents in care.

Deficiencies are cited on the attached LIC 9099-D.

Appeal rights were provided.

An exit interview was conducted, and a copy of the report left at the facility.

SUPERVISOR'S NAME: Anthony Perez	TELEPHONE: (323) 485-4915
LICENSING EVALUATOR NAME: Jacob Williams	TELEPHONE: (916) 809-5764
LICENSING EVALUATOR SIGNATURE:	DATE: 07/19/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/19/2022

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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Document Has Been Signed on 07/20/2022 02:42 PM - It Cannot Be Edited

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
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 07/19/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87411(a)

Personnel Requirements - General

(a) Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs. In facilities licensed for sixteen or more, sufficient support staff shall be employed to ensure provision of personal assistance and care as required in Section 87608, Postural Supports. Additional staff shall be employed as necessary to perform office work, cooking, house cleaning, laundering, and maintenance of buildings, equipment and grounds. The licensing agency may require any facility to provide additional staff whenever it determines through documentation that the needs of the particular residents, the extent of services provided, or the physical arrangements of the facility require such additional staff for the provision of adequate services. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the facility did not comply with the section cited above. LPAs observed facility kitchen staff preparing food without wearing a mask and contracted worker not wearing a mask while giving a resident a manicure which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 07/26/2022
	Plan of Correction
1 2 3 4	Administrator agrees to conduct an in-service and submit a letter of understanding to Licensing on POC due date, 7/26/2022.

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: Anthony Perez	TELEPHONE: (323) 485-4915
LICENSING EVALUATOR NAME: Jacob Williams	TELEPHONE: (916) 809-5764
LICENSING EVALUATOR SIGNATURE:	DATE: 07/19/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/19/2022

LIC809 (FAS) - (06/04)

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