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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 392701057
Report Date: 07/27/2021
Date Signed: 07/27/2021 12:22:27 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 BROOKSIDEFACILITY NUMBER:
392701057
ADMINISTRATOR:HOLGUIN, PATRICIAFACILITY TYPE:
740
ADDRESS:3318 BROOKSIDE ROADTELEPHONE:
(209) 473-1300
CITY:STOCKTONSTATE: CAZIP CODE:
95219
CAPACITY:81CENSUS: 68DATE:
07/27/2021
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
09:58 AM
MET WITH:P. HolguinTIME COMPLETED:
12:00 PM
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Licensing Program Analyst (LPA) Albert Johnson arrived and met with Administrator/ Executive Director, who assisted in conducting this inspection.

LPA toured Physical Plant, Food Service, Common Areas, Bedrooms, Bathrooms, Kitchen and Medication Storage. Fire extinguisher is current and First Aid fully stocked. Kitchen was clean and good repair. Facility is prepared to provide (7) seven days of non-perishable and (2) two days of perishable food required for emergency shelter in place supplies through food stocks. Bedrooms are one bedroom or two bedroom design. Rooms inspected have appropriate items and are in good repair. Water temperatures in bedrooms were measured at 108.7 and 106.9 degrees Fahrenheit in two different locations.

LPA observed medication rooms where centrally stored medications and toxins will be kept, refrigerators, cabinets, and medication carts are locked as well. The medication room doors lock and are inaccessible to residents.

Facility will accept total capacity of 77 non-ambulatory elderly residents; in which 4 may be bedridden. Memory care unit was observed in this facility to be clean, safe, and secured. All common areas appear to be free from hazards, clean and in good repair. The Department has received the fire clearance dated 5/24/2021.

During this visit, this facility is in substantial compliance and meets the minimum requirements for a RCFE license. Component III completed.

Exit interview held with Executive Director and a copy of this report was given at the conclusion of the visit. Application is pending further review.
SUPERVISOR'S NAME: Stephenie DoubTELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Albert JohnsonTELEPHONE: (916) 217-1390
LICENSING EVALUATOR SIGNATURE:

DATE: 07/27/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/27/2021
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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