<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 392701057
Report Date: 12/13/2024
Date Signed: 12/13/2024 11:39:25 AM

Document Has Been Signed on 12/13/2024 11:39 AM - 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/
DIRECTOR:		TRACY BURKEFACILITY TYPE:
740
ADDRESS:3318 BROOKSIDE ROADTELEPHONE:
(209) 473-1300
CITY:STOCKTONSTATE: CAZIP CODE:
95219
CAPACITY: 81CENSUS: DATE:
12/13/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:45 AM
MET WITH:Tracy BurkeTIME VISIT/
INSPECTION COMPLETED:
10:11 AM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
LPA Albert Johnson made an unannounced POC visit to the facility to verify correction of citations issued during case management visits, annuals and complaint investigations.

Deficiencies cited under Title 22 Regulations have been cleared. Licensee complied with the terms of all POCs

Section Cited: 87464(f)(1)Date Due: 05/15/2024
Plan of Correction:
Licensee agrees to submit a plan of correction to LPA by 5/15/2024 on how the facility will be in compliance with regulation 87464(f)(1) at all times.		Corrections:
Cleared By Visit		Clearance Date:
12/13/2024
Section Cited: 87705(c)(5)Date Due: 05/17/2024
Plan of Correction:
All residents diagnosed with dementia will be scheduled with their responsible physician and be assessed for any changes to their needs with an updated LIC 602. 		Corrections:
Cleared By Visit		Clearance Date:
12/13/2024
Section Cited: 87203Date Due: 08/20/2024
Plan of Correction:
Licensee/Administrator will ensure that the fire equipment listed is inspected or a plan is made and sent to CCL by the POC date indicated. Licensee/Administrator shall send picture of the new tags. As proof and submit Statement of Compliance by POC date.		Corrections:
Cleared By Visit		Clearance Date:
12/13/2024

LPA was unable to clear two citations under appeal from 3/14/2024.

Exit interview conducted.
SUPERVISORS NAME: Lisa Rios
LICENSING EVALUATOR NAME: Albert Johnson
LICENSING EVALUATOR SIGNATURE: DATE: 12/13/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/13/2024
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 1