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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 361880764
Report Date: 07/23/2020
Date Signed: 07/28/2020 02:00:56 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME:OAKMONT OF CHINO HILLSFACILITY NUMBER:
361880764
ADMINISTRATOR:AMIRI, AZIZFACILITY TYPE:
740
ADDRESS:14837 PEYTON DRIVETELEPHONE:
(909) 606-3010
CITY:CHINO HILLSSTATE: CAZIP CODE:
91709
CAPACITY:170CENSUS: 119DATE:
07/23/2020
TYPE OF VISIT:Case Management - IncidentANNOUNCEDTIME BEGAN:
03:30 PM
MET WITH:Alexis Perez, Executive DirectorTIME COMPLETED:
04:09 PM
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Licensing Program Analyst (LPA), Stephanie Torres, contacted the facility via telephone to commence a case management televisit due to COVID-19. The LPA identified herself and discussed the purpose of the call with Executive Director (ED), Alexis Perez.

The Department received an Unusual Incident Report (UIR) on July 20, 2020 pertaining to Resident One (R1). The UIR detailed the attempted suicide of R1 on July 18, 2020 at approximately 5:54 PM. The report details staff observing a chair and other items used to block the resident's apartment door. The report mentions staff finding R1 to be sitting on, with their legs hanging over, the ledge of the balcony. The report notes the resident had a knife and rope nearby.

On this visit the LPA conducted staff interviews and, accompanied by Perez, toured the previous and current bedrooms of R1. According to Perez, the resident had no history of self harm or suicidal behavior and the resident's medical assessment noted no diagnosis or early signs of cognitive disease. Perez reported R1's primary physician was contacted on July 18, 2020 and consultation provided by the physician was received and action taken. Perez reported discussion with R1's responsible party on obtaining an updated medical assessment would be conducted, along with an updated Written Record of Care. The LPA will review reports received from the facility and follow-up if necessary. No health and safety concerns were observed on this televisit.

An exit interview was conducted with ED Perez via telephone and a copy of this report was provided to Perez via email. Report with facility representative signature was obtained.
SUPERVISOR'S NAME: Reyna LaceyTELEPHONE: (951) 836-3135
LICENSING EVALUATOR NAME: Stephanie TorresTELEPHONE: (951) 204-5924
LICENSING EVALUATOR SIGNATURE:

DATE: 07/23/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/23/2020
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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