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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 366426338
Report Date: 09/06/2022
Date Signed: 09/06/2022 04:01:23 PM


Document Has Been Signed on 09/06/2022 04:01 PM - It Cannot Be Edited

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
, CA 92507



FACILITY NAME:OAKMONT OF SAN ANTONIO HEIGHTSFACILITY NUMBER:
366426338
ADMINISTRATOR:SAMUEL DE GUZMANFACILITY TYPE:
740
ADDRESS:2419 N EUCLID AVETELEPHONE:
(909) 981-4002
CITY:UPLANDSTATE: CAZIP CODE:
91786
CAPACITY:140CENSUS: 87DATE:
09/06/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:50 AM
MET WITH:Samuel De Guzman, Executive Director
Hollie Shuler, Health Service Director. 		TIME COMPLETED:
12:15 PM
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Licensing Program Analyst (LPA) Amy Goldenberg made an announced visit to the facility. The purpose of the visit was to conduct a required annual inspection, with an emphasis on infection control due to the COVID-19 pandemic. LPA is informed that there are no COVID positive individuals in the home. The facility has an approved mitigation plan on file with this agency. There is one entry point designated where sign in procedures and screening will occur. The staff are temperature screening visitors upon entry into the facility. LPA is informed that there are currently no residents in the home.

LPA conducted a brief tour of the facility and made observations pertaining to the facility's infection control measures. The facility was equipped with sufficient hand hygiene supplies, sufficient cleaning and disinfecting provisions, and has a limited supply of Personal Protective Equipment (PPE). LPA discussed the availability of additional PPE supplies to the facility at the time of this visit and advised the facility representatives to contact our office in the event additional supplies are necessary.

Based on observations made during today’s inspection, there are no deficiencies being cited per Title 22, Division 6, of the California Code of Regulations. LPA reviewed this report with and a copy was provided to the facility representative.
SUPERVISOR'S NAME: Nedra BrownTELEPHONE: (951) 202-5776
LICENSING EVALUATOR NAME: Amy GoldenbergTELEPHONE: (951) 201-3990
LICENSING EVALUATOR SIGNATURE:
DATE: 08/30/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/06/2022
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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