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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 315002955
Report Date: 10/16/2023
Date Signed: 10/16/2023 12:40:36 PM


Document Has Been Signed on 10/16/2023 12:40 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
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827



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: 86DATE:
10/16/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
11:45 AM
MET WITH:Haley ThomasTIME COMPLETED:
12:45 PM
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Licensing Program Analysts (LPA) Kerry Hiratsuka and Lavina Muscan, conducted an unannounced case management visit on 10/16/2023. This visit is to confirm ORDERS TO INDIVIDUAL FOR IMMEDIATE EXCLUSION FROM ALL FACILITIES.

LPAs met with Administrator Haley Thomas and stated the purpose of visit. Facility understands this is an Immediate Exclusion effective 10/16/2023 and S1 is excluded and cannot be allowed to work, live in, and/or have contact with clients in any residential facility licensed by the California Department of Social Services. Therefore, the Department orders the facility to remove S1 from any contact with clients and not allow this employee to be physically present in the facility.

Exit interview conducted, a copy of this report provided on this date. A signature on these forms acknowledges receipt of these forms.
SUPERVISOR'S NAME: Troy OrdonezTELEPHONE: (916) 263-4700
LICENSING EVALUATOR NAME: Kerry HiratsukaTELEPHONE: (916) 591-0210
LICENSING EVALUATOR SIGNATURE:
DATE: 10/16/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/16/2023
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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