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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 347005427
Report Date: 08/18/2021
Date Signed: 08/18/2021 12:33:25 PM

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 FOLSOMFACILITY NUMBER:
347005427
ADMINISTRATOR:ANSARI, POUVAFACILITY TYPE:
740
ADDRESS:1574 CREEKSIDE DRTELEPHONE:
(916) 817-4500
CITY:FOLSOMSTATE: CAZIP CODE:
95630
CAPACITY:88CENSUS: 71DATE:
08/18/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Pouya Ansari (Administrator)TIME COMPLETED:
12:45 PM
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Licensing Program Analyst (LPA) Konnor Leitzell arrived at the facility on 8/18/2021 to conduct a Required-1 Year Inspection utilizing the infection control domain, LPA met with Pouya Ansari (Admin) and explained the purpose of the visit. Prior to initiating the annual inspection, LPA completed required COVID-19 testing protocols, and a daily self-screening questionnaire for symptoms of COVID-19 infection to affirm no COVID-19 related symptoms; contacted admin and completed a facility risk assessment. LPA ensured they applied hand sanitizer before entering the facility and the following Personal Protective Equipment (PPE) was worn: N-95 Masks. Additionally, LPA was screened at entry and answers were documented in their visitor screening log.

LPA and Pouya toured facility together to ensure health and safety of residents in care. Areas toured include but are not limited to: the activity rooms, kitchen, two (2) of two (2) dining rooms, Café, six (6) of six (6) public restrooms, ten (10) of seventy-three (73) apartment; three (3) being shared and seven (7) being individual, movie theater, and reading room. In the areas toured no immediate health, safety, or personal rights violations were observed. LPA and admin completed the infection control domain and facility was found to be in substantial compliance at this time.

No deficiencies are being cited as a result of todays inspection.
Exit interview conducted and copy of report left at the facility.
SUPERVISOR'S NAME: Troy OrdonezTELEPHONE: (916) 263-4832
LICENSING EVALUATOR NAME: Konnor LeitzellTELEPHONE: (916) 708-9618
LICENSING EVALUATOR SIGNATURE:

DATE: 08/18/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/18/2021
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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