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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 392701014
Report Date: 11/04/2021
Date Signed: 11/04/2021 01:01:46 PM

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 LODIFACILITY NUMBER:
392701014
ADMINISTRATOR:PRYOR, JESSICAFACILITY TYPE:
740
ADDRESS:2905 REYNOLDS RANCH PARKWAYTELEPHONE:
(949) 744-5200
CITY:LODISTATE: CAZIP CODE:
95240
CAPACITY:136CENSUS: 57DATE:
11/04/2021
TYPE OF VISIT:Case Management - COVID-19UNANNOUNCEDTIME BEGAN:
10:15 AM
MET WITH:Jessica PryorTIME COMPLETED:
01:10 PM
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On 11/04/21, Licensing Program Analyst (LPA) Mohamed Filouane, conducted a COVID-19 case management health and safety inspection. LPA entered the facility and had his temperature taken and answered a COVID-19 questionnaire by a staff member, following the facility's health and safety procedures. LPA Filouane then met with Executive Director (ED) Jessica Pryor and explained the purpose of the visit.

LPA reviewed the list of advisories recommended to the facility during a prior virtual visit with a different LPA. The ED confirmed completion of certain advisories and verified that certain advisories were in progress. LPA documented the next COVID-19 response testing date, current COVID-19 positive cases in the facility, and number of COVID-19 test results received by the facility. LPA then conducted a tour of the facility alongside the ED.

The physical plant is consistent with the submitted facility floor plan and has COVID-19 health and safety signage. LPA Filouane advised the ED to include additional COVID-19 signage and social distancing signage throughout the facility. There are no obstructions blocking indoor and outdoor passageways. The facility's kitchen is free of debris. Facility refrigerator is stocked with meats, eggs, vegetables, milk, and fruit. Seven-day non-perishable food supply and two-day perishable food supply is sufficient. Beginning at at approximately 11:20 AM, LPA observed the facility's activities room, workout room, salon room, dining room, kitchen, lounge, and media room, then made his way to the memory care unit.
SUPERVISOR'S NAME: Liza KingTELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Mohamed FilouaneTELEPHONE: (916) 263-4700
LICENSING EVALUATOR SIGNATURE:

DATE: 11/04/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/04/2021
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, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
FACILITY NAME: OAKMONT OF LODI
FACILITY NUMBER: 392701014
VISIT DATE: 11/04/2021
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At approximately 11:30 AM, LPA entered the memory care unit (MCU). LPA observed one personal protective equipment station by the entrance doors of the MCU. Additional PPE stations were stationed throughout the MCU. LPA observed a staff member fully clothed in PPE, with a gown, gloves, shoe covers, mask, and a face shield. LPA advised for additional COVID-19 signage and social distancing signage in the MCU. LPA observed the laundry area as clean. The Executive Director stated the facility was taking precautions in separating the laundry of COVID-19 negative residents with COVID-19 positive residents.

LPA then toured the Assisted Living section of the facility with the ED. LPA advised for additional COVID-19 signage and social distancing signage in the Assisted Living section. At the end of this visit, LPA verified that additional signage had been placed throughout the facility for COVID-19 and social distancing.

No deficiencies were cited today. Exit interview conducted with Executive Director. A copy of this report will be given to the facility.
SUPERVISOR'S NAME: Liza KingTELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Mohamed FilouaneTELEPHONE: (916) 263-4700
LICENSING EVALUATOR SIGNATURE:

DATE: 11/04/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/04/2021
LIC809 (FAS) - (06/04)
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