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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 392701057
Report Date: 12/01/2021
Date Signed: 12/01/2021 03:56:55 PM

Document Has Been Signed on 12/01/2021 03:56 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: DATE:
12/01/2021
TYPE OF VISIT:Post LicensingUNANNOUNCEDTIME BEGAN:
01:05 PM
MET WITH:P. HolguinTIME COMPLETED:
03:36 PM
NARRATIVE
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Licensing Program Analyst (LPA) Albert Johnson arrived to conduct an unannounced Post Licensing inspection /case management visit for multiple falls for R1 and a medication error for R2.

LPA reviewed the Personnel Policies, Abuse Reporting Procedures, In-Service Training and Medication Procedures in the file of S1 during the Post-Licensing Inspection.

LPA reviewed R1 and R2's files, during the file review LPA observed that R1 was sent out for a fall on 11/20/2021 and was subsequently diagnosed with kidney failure/kidney injury and has not returned to the facility. R1 does not have a TB test on file. R2 was admitted to hospice on 5/20/2021.

LPA observed the following posted at the entrance of the facility: See Something Say Something complaint poster, Reporting Requirements per AB40, Resident Bill of rights, Resident Personal Rights, Evacuation Routes and facility license were all posted as required.

Exit interview held with Administrator and a copy of report given along with appeal rights at the conclusion of the visit.
SUPERVISORS NAME: Stephenie Doub
LICENSING EVALUATOR NAME: Albert Johnson
LICENSING EVALUATOR SIGNATURE: DATE: 12/01/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/01/2021
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 12/01/2021 03:56 PM - It Cannot Be Edited


Created By: Albert Johnson On 12/01/2021 at 03:05 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

FACILITY NAME: OAKMONT OF BROOKSIDE
FACILITY NUMBER: 392701057

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/01/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
12/16/2021
Section Cited

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87458(b)(1) Medical Assessment. The medical assessment, at a minimum, shall include: A physical exam of the resident containing a primary and secondary diagnosis, if any, results of a test
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for tuberculosis and any medical conditions which would preclude care of the person in an RCFE. R1 does not have a current TB test. This poses a potential 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:Stephenie Doub
LICENSING EVALUATOR NAME:Albert Johnson
LICENSING EVALUATOR SIGNATURE:
DATE: 12/01/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/01/2021


LIC809 (FAS) - (06/04)
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