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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 392701014
Report Date: 09/09/2022
Date Signed: 09/09/2022 05:52:24 PM


Document Has Been Signed on 09/09/2022 05:52 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, 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: 103DATE:
09/09/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
04:00 PM
MET WITH:Sara MackedsyTIME COMPLETED:
05:52 PM
NARRATIVE
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On 9-9-22 at 4:00pm, Licensing Program Analyst (LPA) Michael Bilger arrived at facility unannounced to conduct a case management visit regarding incident reporting for bed bug incidents occurring on 8-18-22 and 8-27-22. Based on record review and interview, it was determined that facility noted bed bugs in various rooms on the above dates, and did not furnish a copy of the incident report to licensing.

As a result of today’s case management visit, citation is issued under Title 22, Division 6, Chapter 8. A civil penalty in the amount of $250 is issued in addition to the citation due to repeat violation within a 12-month period. An exit interview was conducted with Sara Mackedsy and a copy of this report was left with Sara. Appeal rights provided.

SUPERVISOR'S NAME: Liza KingTELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Michael BilgerTELEPHONE: 916-862-4722
LICENSING EVALUATOR SIGNATURE:
DATE: 09/09/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/09/2022
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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Document Has Been Signed on 09/09/2022 05:52 PM - It Cannot Be Edited

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

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/09/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/19/2022
Section Cited

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Reporting Requirements:(a) Each licensee shall furnish to the licensing agency such reports...(1) A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days..(D) Any incident which threatens the welfare, safety or health...
This requirement was not met as evidence by:
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Based on documentation and interviews, licensee did not ensure incident report was sent to Licensing department regarding bed bug occurrences on 8-18-22 and 8-27-22 which poses as a potential health and safety risks to residents in care. A civil penalty is issued due to repeat violation within 12-month period.
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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: Liza KingTELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Michael BilgerTELEPHONE: 916-862-4722
LICENSING EVALUATOR SIGNATURE:
DATE: 09/09/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/09/2022
LIC809 (FAS) - (06/04)
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