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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 345002797
Report Date: 07/29/2022
Date Signed: 07/29/2022 05:00:23 PM


Document Has Been Signed on 07/29/2022 05:00 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 FAIR OAKSFACILITY NUMBER:
345002797
ADMINISTRATOR:CONDIE, NATHANFACILITY TYPE:
740
ADDRESS:8484 MADISON AVE.TELEPHONE:
(916) 633-1001
CITY:FAIR OAKSSTATE: CAZIP CODE:
95628
CAPACITY:128CENSUS: 87DATE:
07/29/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:35 PM
MET WITH:Pouya Ansari, Executive Director TIME COMPLETED:
04:00 PM
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Licensing Program Analyst (LPA) Sabrina Calzada arrived unannounced to conduct a required annual inspection. LPA met with Pouya Ansari, Executive Director, and explained purpose of inspection.
Prior to initiating today's inspection, LPA completed required COVID-19 testing protocols and completed a daily self-screening questionnaire for symptoms of COVID-19 infection to affirm no COVID-19 related symptoms. Additionally, LPA was screened per Covid-19 precautionary measures upon entering the community. LPA ensured she applied hand sanitizer before entering the facility and the following Personal Protective Equipment (PPE) was worn: N95 mask.The facility is licensed for (128) non-ambulatory residents, (8) of which may be bedridden and has a hospice waiver for (15).

LPA and Executive Director toured the interior and exterior of the Assisted Living Unit (ALU) and Memory Care Unit (MCU) including the medication room, dining room, activity room, and common areas. Also observed in the ALU area were the theater, library, salon, massage and physical therapy room. ALU and MCU each have their own enclosed outside patios. LPA observed the facility to be clean, in good repair and to be odor free and the bathrooms to have paper towels, soap- trash cans with lids to be added. Facility to ensure 20-second hand-washing posters are placed by each bathroom/kitchen sink. Fire extinguishers observed throughout and were last serviced on 2/8/2022. Facility conducts quarterly fire drills. Facility had inside temperature of 73*F. LPA observed 2+day perishable and 7+day non-perishable food supply and a 7-day emergency food/water supply. LPA observed standing hand sanitizers throughout (6) and required postings displayed. Facility to post Covid social distancing signs near elevators and in staff break rooms. Discussed vaccination protocols of residents and staff and visitation protocols in place. Booster #2 clinic to be scheduled in upcoming weeks. Department PPE supplies (gloves) provided during today's inspection. LPA requested a copy of LIC308, LIC500 and current liability insurance be emailed to CCLD by 8/5/2022.. There were no deficiencies observed during today's inspection.

Exit interview. Copy of report left at facility.
SUPERVISOR'S NAME: Maribeth SentyTELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Sabrina CalzadaTELEPHONE: (510) 829-2133
LICENSING EVALUATOR SIGNATURE:
DATE: 07/29/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/29/2022
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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