342700796-4-21-2021-27-AS-TTRG-C2AW2J-20210421165425

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 342700796
Report Date: 04/19/2021
Date Signed: 04/21/2021 04:54:33 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

FACILITY NAME:	OAKMONT OF EAST SACRAMENTO		FACILITY NUMBER:	342700796
ADMINISTRATOR:	ERVIN, TERENCE		FACILITY TYPE:	740
ADDRESS:	5301 F STREET		TELEPHONE:	(916) 905-2400
CITY:	EAST SACRAMENTO	STATE: CA	ZIP CODE:	95819
CAPACITY:	214; 214	CENSUS: 85	DATE:	04/19/2021
TYPE OF VISIT:	Case Management - Other	UNANNOUNCED	TIME BEGAN:	11:10 AM
MET WITH:	Terry Ervin, Administrator		TIME COMPLETED:	11:50 AM

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) Tung Truong contacted the facility via FaceTime to conduct a case management on 04/19/2021 due to concerns about the facility. LPA identified himself and discussed the purpose of the call and the elements of the case management with Administrator Terry Ervin. The purpose of the case management visit was to follow up on concerns learned through a complaint. LPA toured the outside and inside of the facility with the administrator. LPA observed the front entrance, main lobby area, library, activity room, dining area, bar/lounge area and two resident’s apartments. Facility was clean and in good repair. The following concerns were discussed during this televisit: - Residents rooms are dirty. - Residents laundry is not being done - Facility is not providing safe accommodations for residents. LPA requested Administrator to provide the police report on incidents of breaking and entering. Continued on LIC 809-C

SUPERVISOR'S NAME: Czarrina A Camilon-Lee	TELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Tung Truong	TELEPHONE: (916) 201-7895
LICENSING EVALUATOR SIGNATURE:	DATE: 04/19/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/19/2021

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, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

FACILITY NAME: OAKMONT OF EAST SACRAMENTO	FACILITY NUMBER: 342700796
	VISIT DATE: 04/19/2021

NARRATIVE

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The following deficiency was observed and cited on the LIC 809-D pursuant to the California Code of Regulations, Title 22, and California Health and Safety Code.

Exit interview conducted with Administrator. Copy of LIC 809, LIC 809-C, LIC 809-D, and appeal rights will be sent via email. The Administrator is to review, sign it. and email back to the LPA. Failure to correct any deficiencies by plan of correction due date(s) may result in civil penalties.

SUPERVISOR'S NAME: Czarrina A Camilon-Lee	TELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Tung Truong	TELEPHONE: (916) 201-7895
LICENSING EVALUATOR SIGNATURE:	DATE: 04/19/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/19/2021

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, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

FACILITY NAME: OAKMONT OF EAST SACRAMENTO	FACILITY NUMBER: 342700796
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 04/19/2021

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 04/21/2021 Section Cited	1 2 3 4 5 6 7	87211. Reporting Requirements. Each licensee shall furnish to the licensing agency such reports...Any incident which threatens the welfare, safety or health of any resident, such as psychological abuse of a resident by staff or other residents, or unexplained absence of any resident. This requirement is not met as evidence by:
	8 9 10 11 12 13 14	Based on interview and records review the Licensee did not submit a written incident report of a breaking and entering incident to the Department which poses a potential health and safety risk to residents in care.	8 9 10 11 12 13 14
	1 2 3 4 5 6 7
	1 2 3 4 5 6 7

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: Czarrina A Camilon-Lee	TELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Tung Truong	TELEPHONE: (916) 201-7895
LICENSING EVALUATOR SIGNATURE:	DATE: 04/19/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/19/2021

LIC809 (FAS) - (06/04)

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