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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 345002797
Report Date: 08/30/2022
Date Signed: 08/30/2022 02:52:44 PM


Document Has Been Signed on 08/30/2022 02:52 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: 82DATE:
08/30/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
02:45 PM
MET WITH:Pouya Ansari, Administrator TIME COMPLETED:
03:00 PM
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Licensing Program Analyst (LPA) Sabrina Calzada arrived unannounced to issue a related deficiency to complaint # 25-AS-20211027124047 that was opened/closed under the facility's prior license that was open through 7/27/2021. Complaint findings for this complaint were issued on August 2, 2022. LPA met with Administrator, Pouya Ansari, and explained the 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: surgical mask.

This report was created to document today's inspection under the current license and that a $500.00 penalty is being issued to the facility pursuant to Health and Safety Code section 1569.49(c)(1) - a violation that resulted in the injury or illness of a resident. The violation occurred from February 2020- August 2020,

There are no deficiencies issued on this report.

Exit interview. Copy of report left with Administrator.
SUPERVISOR'S NAME: Maribeth SentyTELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Sabrina CalzadaTELEPHONE: (510) 829-2133
LICENSING EVALUATOR SIGNATURE:
DATE: 08/30/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/30/2022
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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