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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 347005427
Report Date: 08/29/2024
Date Signed: 08/29/2024 10:23:56 AM


Document Has Been Signed on 08/29/2024 10:23 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 2525 NATOMAS PARK DR STE 270
SACRAMENTO, CA 95833



FACILITY NAME:OAKMONT OF FOLSOMFACILITY NUMBER:
347005427
ADMINISTRATOR:CLYMO, MICHAELFACILITY TYPE:
740
ADDRESS:1574 CREEKSIDE DRTELEPHONE:
(916) 817-4500
CITY:FOLSOMSTATE: CAZIP CODE:
95630
CAPACITY:88CENSUS: 71DATE:
08/29/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
09:40 AM
MET WITH:Kelly Kolodziej, Health Services DirectorTIME COMPLETED:
10:45 AM
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Licensing Program Analyst (LPA) Bethany Mirlohi arrived unannounced to conduct a case management visit. LPA met with Health Services Director Kelly Kolodziej during today's inspection.

LPA arrived to review a death report received from the facility. LPA requested copies of R1 resident file and documentation. LPA spoke to Health Services Director about the incident.

During today's inspection no deficiencies were cited.

Exit interview conducted and copy of report provided.
SUPERVISOR'S NAME: Troy OrdonezTELEPHONE: (916) 263-4832
LICENSING EVALUATOR NAME: Bethany MirlohiTELEPHONE: (916) 204-8288
LICENSING EVALUATOR SIGNATURE:
DATE: 08/29/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/29/2024
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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