361881162-7-29-2021-18-AS-EWEY-C5DSV6-20210729141211

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 361881162
Report Date: 07/29/2021
Date Signed: 07/29/2021 02:12:16 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 HILLS		FACILITY NUMBER:	361881162
ADMINISTRATOR:	MEDRANO, JANETH		FACILITY TYPE:	740
ADDRESS:	14837 PEYTON DRIVE		TELEPHONE:	9096063010
CITY:	CHINO HILLS	STATE: CA	ZIP CODE:	91709
CAPACITY:	170	CENSUS: 118	DATE:	07/29/2021
TYPE OF VISIT:	Prelicensing	UNANNOUNCED	TIME BEGAN:	09:15 AM
MET WITH:	Administrator, Janeth Medrano		TIME COMPLETED:	02:11 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 Analysts (LPA) Elecia Weathersby conducted an announced visit to the facility for purpose of a Pre-Licensing evaluation (CHOW). At approximately 9:15AM, LPA Weathersby met with Administrator Janeth Medrano. An initial application to operate an Residential Care for the Elderly facility (RCFE) was submitted to the Central Applications Bureau (CAB) in April 2021 for a total capacity of (170) which includes (155) non-ambulatory and up to (15) bedridden residents. Fire clearance was granted on 06/11/21. LPA Elecia Weathersby observed the following: Structure: Facility was a split four (4) story building with nine (9) common area public bathrooms and (129) personal apartment units, which include (26) memory care units. Heating/Cooling System: Central heating and air conditioning system installed throughout the facility. Temperatures were consistently comfortable throughout the facility between 73-77 degrees Fahrenheit (F), due to extreme outdoor temperatures. Apartments: LPA observed adequate furnishing in occupied apartments consistent with beds, chairs, closets, appropriate linens, adequate lighting, and dining tables. Each accessed apartment equipped with standard appliances such as stove, refrigerator, microwave, dishwasher. Bathrooms: Each residents unit has personal bathrooms, toilet, sink, and shower. Kitchen/Laundry: An adequate supply of dishes, glasses, utensils, pots and pans were observed. Knives/sharp instruments were secured in a locked drawer located in the kitchen. There was adequate room for food storage. LPA observed the stove to be operational. Refrigerator/freezer were in working condition (CONTINUED ON LIC 812C)

SUPERVISOR'S NAME: Efren Malagon	TELEPHONE: (951) 248-0337
LICENSING EVALUATOR NAME: Elecia Weathersby	TELEPHONE: (951) 255-9516
LICENSING EVALUATOR SIGNATURE:	DATE: 07/29/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/29/2021

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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

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 HILLS	FACILITY NUMBER: 361881162
	VISIT DATE: 07/29/2021

NARRATIVE

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(CONTINUED FROM LIC 812)
and had sufficient storage for perishable food. There was adequate seating for meals for all clients.
Laundry rooms with washer and dryer was located on each floor.
Living/Family room:
There were open seating areas throughout the facility with safe and adequate seating for residents in care.
Yards/Outside:
LPA observed adequate patio shade coverage and sufficient outdoor seating for residents and guest. Fencing secured the entire back building area. All outdoor pathways were free of obstructions. LPA observed an outdoor fenced pool which was locked and requiring repairs related to quality of water, fencing, and electrical hazards (per County of San Bernardino as of 7/22/2021).
Emergency Phone Numbers, and Exit Plan:
Facility sketch, Ombudsman poster observed, emergency phone numbers were observed posted in the main 2^nd floor area.
General items:
Facility equipped with more than (200) hardwired, working smoke detectors and (36) fire extinguishers. LPA observed all to be charged and serviced within the past year (verification obtained) and located throughout the facility. Client medications and records will be stored in locked medication rooms. First Aid kit with required components, and locked area for medication storage was observed. LPA observed a facility phone and it was verified to be operational as evidenced by LPA dialing the number to trigger a ring.
Component III:
LPA conducted the component III training with the Administrator on this date.
Pre-Licensing is incomplete and the following deficiencies to be resolved by 8/5/2021:
Water Quality
Electrical Hazards - Lighting
See something say something poster and Ombudsman poster, posted in obscure areas (Should be visible to staff, residents, and guest).

A follow up Pre-Licensure LIC809 will be generated upon resolution of deficiencies on 8/5/2021..

SUPERVISOR'S NAME: Efren Malagon	TELEPHONE: (951) 248-0337
LICENSING EVALUATOR NAME: Elecia Weathersby	TELEPHONE: (951) 255-9516
LICENSING EVALUATOR SIGNATURE:	DATE: 07/29/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/29/2021

LIC809 (FAS) - (06/04)

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