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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 315002955
Report Date: 01/25/2024
Date Signed: 01/25/2024 10:46:15 AM


Document Has Been Signed on 01/25/2024 10:46 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 2525 NATOMAS PARK DR STE 270
SACRAMENTO, CA 95833



FACILITY NAME:OAKMONT OF WESTPARKFACILITY NUMBER:
315002955
ADMINISTRATOR:THOMAS, HALEYFACILITY TYPE:
740
ADDRESS:2400 PLEASANT GROVE BLVD.TELEPHONE:
(916) 545-8904
CITY:ROSEVILLESTATE: CAZIP CODE:
95747
CAPACITY:142CENSUS: 83DATE:
01/25/2024
TYPE OF VISIT:Case Management - Annual ContinuationUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Haley Thomas, AdministratorTIME COMPLETED:
11:00 AM
NARRATIVE
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Licensing Program Analyst (LPA) Bethany Mirlohi arrived unannounced to continue annual inspection. LPA met with Haley Thomas during today's inspection.

LPA toured facility with administrator to ensure health and safety of residents in care. LPA toured 6 resident rooms, medication room, staff area, bathrooms, kitchen, common living spaces, outdoor spaces, and activity areas. In the areas toured no immediate health, safety, or personal rights violations were observed. LPA toured the assisted living side of the facility and the memory care unit with an approved delayed egress. There is a locked storage for medications and toxins. Food supply is adequate for 2-day perishable and 7-day nonperishable. LPA observed an adequate amount of linens and found the first aid kit to be complete. Hot water was measured at 118 degrees. LPA reviewed 4 resident medications comparing with current physician orders. LPA interviewed residents and staff.

Deficiencies are cited on 809-D.

Exit interview conducted and appeal rights provided.
SUPERVISOR'S NAME: Troy OrdonezTELEPHONE: (916) 263-4832
LICENSING EVALUATOR NAME: Bethany MirlohiTELEPHONE: (916) 204-8288
LICENSING EVALUATOR SIGNATURE:
DATE: 01/25/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/25/2024
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 01/25/2024 10:46 AM - 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
SACRAMENTO NORTH ASC, 2525 NATOMAS PARK DR STE 270
SACRAMENTO, CA 95833


FACILITY NAME: OAKMONT OF WESTPARK
FACILITY NUMBER: 315002955

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/25/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87355(e)(3)
Criminal Record Clearance
(e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility: (3) Request a transfer of a criminal record clearance as specified in Section 87355(c) or

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in 1 out of 10 persons which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 02/01/2024
Plan of Correction
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Administrator and LPA were able to associate staff to facility. Administrator agrees to send into CCL a plan on how facility will ensure all staff are fingerprint cleared and associated. Plan to be sent into CCL by 2/01/24.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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: Troy OrdonezTELEPHONE: (916) 263-4832
LICENSING EVALUATOR NAME: Bethany MirlohiTELEPHONE: (916) 204-8288
LICENSING EVALUATOR SIGNATURE:
DATE: 01/25/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/25/2024
LIC809 (FAS) - (06/04)
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