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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 392701057
Report Date: 10/22/2021
Date Signed: 10/22/2021 02:55:13 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:
10/22/2021
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:P HolguinTIME COMPLETED:
03:10 PM
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Licensing Program Analyst (LPA) Albert Johnson conducted an unannounced case management visit for clarification of an incident that was reported on 10/09/21. LPA met with Patricia Holugin and stated the reason for the visit.

LPA Johnson reviewed documents from multiple doctor's visit in October of 2021, R1 is being treated for Arthralgia and an ongoing issue with a wound on the buttocks. The facility received discharge papers with medication (Lidocaine) to be picked up at the pharmacy on 10/2/2021. The discharge papers did not have a doctor's signature electronically or an original signature. The facility requested via fax to the doctor's office to have the order confirmed. Once confirmed the facility followed the orders of the doctor. On 10/7/2021, the facility received a letter from R1's doctor requesting the start of a topical ointment at 12.8%. The letter was not signed by the doctor. The facility requested to have the order signed and clarification of the area to apply the ointment, it was signed on 10/8/2021 by R1's doctor and the facility complied with the orders.

Based on the records reviewed, the facility complied with the orders of the doctor after receiving clarification of orders and obtained the signed documents from R1's doctor. Also noted, the facility has three fax lines that are operational.

No deficiencies cited
SUPERVISOR'S NAME: Stephenie DoubTELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Albert JohnsonTELEPHONE: (916) 217-1390
LICENSING EVALUATOR SIGNATURE:

DATE: 10/22/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/22/2021
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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