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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 392701057
Report Date: 07/17/2023
Date Signed: 07/17/2023 01:06:08 PM


COMPREHENSIVE INSPECTION

Document Has Been Signed on 07/17/2023 01:06 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 BROOKSIDEFACILITY NUMBER:
392701057
ADMINISTRATOR:HOLGUIN, PATRICIAFACILITY TYPE:
740
ADDRESS:3318 BROOKSIDE ROADTELEPHONE:
(209) 473-1300
CITY:STOCKTONSTATE: CAZIP CODE:
95219
CAPACITY:81CENSUS: 70DATE:
07/17/2023
TYPE OF VISIT:Case Management - Annual ContinuationUNANNOUNCEDTIME BEGAN:
09:50 AM
MET WITH:P. HolguinTIME COMPLETED:
01:30 PM
NARRATIVE
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Licensing Program Analyst (LPA) Albert Johnson conducted an unannounced Case management -annual continuation at the facility today from the annual visit initiated on 7/11/2023.

LPA continued with facilities' annual survey with the assistance of the Administrator.

LPA toured the facility with Staff, reviewed resident records and medication procedures.

During the tour of the facility LPA, Administrator and kitchen staff observed expired food in the main kitchen area, uncovered food in the refrigerator, missing temperature checks for foods served, and no labels on prepared food items stored in the mini refrigerator and the main refrigerator.

Per California Code of Regulations, Title 22 Division 6, Chapter 8, Type B deficiencies were observed cited during this visit.

Exit interview held.

SUPERVISOR'S NAME: Stephenie DoubTELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Albert JohnsonTELEPHONE: (916) 217-1390
LICENSING EVALUATOR SIGNATURE:
DATE: 07/17/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/17/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2


Document Has Been Signed on 07/17/2023 01:06 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 BROOKSIDE
FACILITY NUMBER: 392701057

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/17/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
07/24/2023
Section Cited
CCR
87555(b)(9)

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(b) The following food service requirements shall apply:.....
(9) Procedures which protect the safety, acceptability and nutritive values of food shall be observed in food storage, preparation and service.
This requirement was not met as evidenced by:
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Facility agrees to a deep cleaning of kitchen and food storage area. The facility manager indicated that a kitchen staff membesr recently ended their employment and new kitchen staff are on board.
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 LPA, Administrator and kitchen staff observed expired food in the main kitchen area, uncovered food, missing temperature checks for foods served, and no labels on prepared food
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Facility agrees that kitchen staff will be trained and monitored on proper sanitation practices as well as food storage and service. The facility will provide the department with an in- service agenda with those that attend by the POC date of 7/24/2023

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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: Stephenie DoubTELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Albert JohnsonTELEPHONE: (916) 217-1390
LICENSING EVALUATOR SIGNATURE:
DATE: 07/17/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/17/2023
LIC809 (FAS) - (06/04)
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