<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 347005426
Report Date: 03/15/2021
Date Signed: 03/15/2021 03:15:13 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 CARMICHAELFACILITY NUMBER:
347005426
ADMINISTRATOR:NATHAN CONDIEFACILITY TYPE:
740
ADDRESS:4717 ENGLE RDTELEPHONE:
(916) 483-3800
CITY:CARMICHAELSTATE: CAZIP CODE:
95608
CAPACITY:101CENSUS: 66DATE:
03/15/2021
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
02:30 PM
MET WITH:Amardip Singh, Resident Care Coordinator TIME COMPLETED:
03:15 PM
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) Sabrina Calzada contacted Amardip Singh, Resident Care Coordinator (RCC), by phone on 3/15/2021 to follow up on an incident report the department received by email on 3/14/2021 for resident (R1). LPA confirmed with Nathan Condie, Executive Director, to follow up with RCC who had submitted the unusual incident/injury report (LIC624). LPA explained reason for today's phone call to RCC.

During today's phone call, LPA and RCC discussed in more detail the LIC624 submitted for the incident when resident fell when trying to enter the elevator. LPA requested additional documentation from resident's file, including: physician's report, last (2) care plans, fall plan, charting notes. RCC agreed to provide requested documentation as well as internal report that resident did not use her pendant. to request assistance prior to using the elevator. RCC agreed to provide requested documentation to the department by fax by tomorrow morning, 3/16/2021.

RCC confirmed that resident was taken by 911 for further medical evaluation, contrary to what is indicated in the LIC624.

There are no deficiencies being cited in this case management report.

A copy of this report was emailed to RCC following today' phone call to review, sign and return to the department by end of day, 3/15/2021.
SUPERVISOR'S NAME: Maribeth SentyTELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Sabrina CalzadaTELEPHONE: (510) 829-2133
LICENSING EVALUATOR SIGNATURE:

DATE: 03/15/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/15/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC809 (FAS) - (06/04)
Page: 1 of 1