392700339-5-12-2021-27-AS-AJON-C2XL5V-20210512082747

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 392700339
Report Date: 05/07/2021
Date Signed: 05/12/2021 08:28:02 AM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

FACILITY NAME:	OAKMONT OF BROOKSIDE		FACILITY NUMBER:	392700339
ADMINISTRATOR:	HOLGUIN, PATRICIA (PATTY)		FACILITY TYPE:	740
ADDRESS:	3318 BROOKSIDE RD		TELEPHONE:	(209) 473-1300
CITY:	STOCKTON	STATE: CA	ZIP CODE:	95219
CAPACITY:	81	CENSUS: 64	DATE:	05/07/2021
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	10:30 AM
MET WITH:	Patty Holguin		TIME COMPLETED:	04:45 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 Analyst (LPA) Albert Johnson conducted an unannounced annual/random visit on this date. LPA met with Administrator and explained the purpose of the visit. LPA inspected physical plant including but not limited to kitchen, resident's bedrooms, bathrooms, living/ common areas and dining room area. LPA observed sufficient furniture and lighting throughout the facility. LPA observed sufficient seven day non-perishable and two day perishable food supplies. Hot water temperature was measured at 129 degrees Fahrenheit in resident's 124 and 129 bathroom sinks in the memory care area, which is not within the required range of 105 to 120 degrees. Fire extinguishers and smoke detectors are current and in compliance with fire safety. Carbon dioxide monitor present. LPA observed centrally stored medications locked inside the medication room. LPA reviewed and compared resident medication vs. resident medication logs. During the medication review, LPA observed medication for R1 being used to satisfy two prescriptions or orders. The first order is for a routine 1 mg. tablet every 8 hours around the clock. The other is written as take one 0.5 mg. tablet as needed for anxiety.

SUPERVISOR'S NAME: Stephenie Doub	TELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Albert Johnson	TELEPHONE: (916) 217-1390
LICENSING EVALUATOR SIGNATURE:	DATE: 05/07/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/07/2021

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)

Page: 3 of 9

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

FACILITY NAME: OAKMONT OF BROOKSIDE	FACILITY NUMBER: 392700339
	VISIT DATE: 05/07/2021

NARRATIVE

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The facility should have two medications for these orders, however they are using one order for both prescriptions. LPA and Administrator reviewed 20 resident and 5 staff files, including criminal record clearances. All staff today are Fingerprint cleared and associated to the facility. First aid kit was checked and is complete. Fire drill was completed on 4/2/2021.

Per California Code of Regulations, Title 22 Division 6, Chapter 8 and Health and Safety Code, deficiencies were observed and cited during this visit. Exit interview held and a report given at the conclusion of the visit.

SUPERVISOR'S NAME: Stephenie Doub	TELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Albert Johnson	TELEPHONE: (916) 217-1390
LICENSING EVALUATOR SIGNATURE:	DATE: 05/07/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/07/2021

LIC809 (FAS) - (06/04)

Page: 7 of 9

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

FACILITY NAME: OAKMONT OF BROOKSIDE	FACILITY NUMBER: 392700339
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 05/07/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87303(e)(3)

Maintence and operations: Taps delivering water above 120 f or above shall be prominently identifed by warning signs.
	Deficient Practice Statement
1 2 3 4	This requirement is not met by evidence by:Based on observation and testing the licensee did not maintain water temperature to be within regulatory range. resident's sink hot water measured at 129 *F without a prominently placed warning sign present which poses an immediate risk to staff and residents in care.
	POC Due Date: 05/08/2021
	Plan of Correction
1 2 3 4	Administrator shall lower the thermostat and agreed to test the hot water for 3 days. Test hot water in the bathroom to meet Title 22 regulations. Send 3 day hot water temperature to LPA.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

SUPERVISOR'S NAME: Stephenie Doub	TELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Albert Johnson	TELEPHONE: (916) 217-1390
LICENSING EVALUATOR SIGNATURE:	DATE: 05/07/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/07/2021

LIC809 (FAS) - (06/04)

Page: 8 of 9

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

FACILITY NAME: OAKMONT OF BROOKSIDE	FACILITY NUMBER: 392700339
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 05/07/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

80075(b)(7)

Health related services
	Deficient Practice Statement
1 2 3 4	Health Related Services. For every prescription and nonprescription PRN medication for which the licensee provides assistance, there shall be a signed, dated written order from a physician on a prescription blank, maintained in the client's file, and a label on the medication. This requirement was not met as evidenced by, LPA reviewed medication administration records for R1 and observed medication for R1 being used to satisfy two prescriptions or orders. The first order is for a routine 1 mg. tablet every 8 hours around the clock. The other is written as take one 0.5 mg. tablet as needed for anxiety.
	POC Due Date: 05/21/2021
	Plan of Correction
1 2 3 4	The facility will have a presciption written for each medication with the correct information as prescribed on the label of the medication that identifies the correct information as prescribed by the POC date 5/21/2021

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

SUPERVISOR'S NAME: Stephenie Doub	TELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Albert Johnson	TELEPHONE: (916) 217-1390
LICENSING EVALUATOR SIGNATURE:	DATE: 05/07/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/07/2021

LIC809 (FAS) - (06/04)

Page: 9 of 9