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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 366426338
Report Date: 03/08/2023
Date Signed: 03/08/2023 10:25:39 AM


Document Has Been Signed on 03/08/2023 10:25 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
SAN BERNARDINO, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, 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: 86DATE:
03/08/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
09:15 AM
MET WITH:Cheryl StevensonTIME COMPLETED:
10:45 AM
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Licensing Program Analyst (LPA) Paola Guerrero made an unannounced visit to the facility. LPA arrived at the facility to conduct a case management visit to follow up on a residents death. LPA met with Administrator Cheryl Stevenson and explained the purpose of today's visit.

This case management visit consisted of collecting pertinent documentation and conducting staff interviews regarding the death of Residents #1 (R1) who passed away on 3/5/2023. LPA interviewed Staff #1 (S1) for further information regarding the death of R1 and the events that led up to R1's death. S1 stated that no official death certificate has been issued at this time, but the preliminary cause of death is still undetermined by the local Coroner's office. LPA has advised Facility Administrator Cheryl Stevenson to send a copy of the death certificate to the Community Care Licensing Division (Department) Riverside Regional Office as soon as it is available.


No deficiencies were cited during this visit. An exit interview was conducted where this report (LIC 809) was discussed and provided to the Administrator Cheryl Stevenson.
SUPERVISOR'S NAME: Efren MalagonTELEPHONE: (951) 202-6356
LICENSING EVALUATOR NAME: Paola GuerreroTELEPHONE: (951) 473-7024
LICENSING EVALUATOR SIGNATURE:
DATE: 03/08/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/08/2023
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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