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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 392701057
Report Date: 01/16/2024
Date Signed: 01/16/2024 02:09:45 PM


Document Has Been Signed on 01/16/2024 02:09 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
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827



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: 78DATE:
01/16/2024
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Tracy BurkeTIME COMPLETED:
02:15 PM
NARRATIVE
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LPA Albert Johnson made an unannounced visit to the facility to open a complaint and to verify that the facility has an administrator to replace the current administrator who's last day of work as the administrator was 1/12/2024.

The facility has identified an interim Administrator(No documents sent to the department . The facility has not provided the required documentation to the department to assist with the transfer of administrator's responsibilities and will be given a citation today.

Based on records reviewed and interviews with S1 on 1/16/2024 the facility does not have an Administrator of record. S1 is working here on an interim bases until the permanent administrator's including documents/information is forwarded to the department.

The department was unable to confirm through Licensing Information System that interim Administrator is associated to this facility as of 1/16/2024.


Exit interview conducted, a copy of this report and appeal rights given.
SUPERVISOR'S NAME: Lisa RiosTELEPHONE: (916) 969-9685
LICENSING EVALUATOR NAME: Albert JohnsonTELEPHONE: (916) 217-1390
LICENSING EVALUATOR SIGNATURE:
DATE: 01/16/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/16/2024
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 01/16/2024 02:09 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
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827


FACILITY NAME: OAKMONT OF BROOKSIDE
FACILITY NUMBER: 392701057

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/16/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
01/17/2024
Section Cited
CCR
87405(a-d)

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87405(a-d) All Facilities shall have a qualified and currently certified administrator....
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Licensee will submit to LPA an updated LIC500, LIC200 and other documents required with an employee who has a current administrator certificate and who will act in the administrator capacity until Licensee finds and updates the
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This requirement was not met as evidenced by records reviewed and interviews with staff. This is an immediate risk to operations and care of residents.
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Administrator positions. Licensee will send to LPA by end of day on 1/17/2024
Type A
01/17/2024
Section Cited
CCR87355(e)(2)

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(e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility: (2) Request a transfer of a criminal record clearance as specified in Section 87355(c) or...
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The Licensee will request a criminal record transfer for S1. The Licensee will review the staff roster and ensure all working staff are associated to the facility. Proof of S1 being associated to the facility due by the POC due date of 1/17/2024.
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Based on observation, the Licensee did not ensure all staff were associated to the facility. The LPA observed that S1 was not associated to the facility. This poses an immediate health and safety risk to residents in care.
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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: Lisa RiosTELEPHONE: (916) 969-9685
LICENSING EVALUATOR NAME: Albert JohnsonTELEPHONE: (916) 217-1390
LICENSING EVALUATOR SIGNATURE:
DATE: 01/16/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/16/2024
LIC809 (FAS) - (06/04)
Page: 2 of 2