392701057-8-19-2024-27-AS-AJON-D8AVYT-20240819165140

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 392701057
Report Date: 08/19/2024
Date Signed: 08/19/2024 04:51:51 PM

Document Has Been Signed on 08/19/2024 04:51 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 BROOKSIDE		FACILITY NUMBER:	392701057
ADMINISTRATOR:	TRACY BURKE		FACILITY TYPE:	740
ADDRESS:	3318 BROOKSIDE ROAD		TELEPHONE:	(209) 473-1300
CITY:	STOCKTON	STATE: CA	ZIP CODE:	95219
CAPACITY:	81	CENSUS: 72	DATE:	08/19/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	10:30 AM
MET WITH:	Tracy Burke		TIME COMPLETED:	03:45 PM

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	Licensing Program Analyst (LPA) Albert Johnson arrived unannounced to conduct an Annual Inspection on today's date of 8/19/2024. The LPA met with Tracy Burke. The facility is a two story structure located in North Stockton with a capacity to serve 81 resident and a current census of 72. The grounds were observed to be maintained and clear of obstruction and debris. There is sufficient outdoor furniture for the residents to participate in outdoor activities and pergolas for shade. LPA and Staff inspected the physical plant at to ensure the health and safety of the clients in care. LPA inspected the facility with Staff including but not limited to the kitchen area, resident rooms, bathrooms, dining room, and storage areas. The facility had the required carbon monoxide detectors. LPA observed the facility to be free of odor. LPA observed sufficient lighting throughout the facility. Fire extinguishers and smoke detectors are current and in compliance with fire safety. However, during the tour of the kitchen, LPA and Dietary Supervisor observed out dated Ansul/Fixed system. The system was due for semi-annual service on 3/2024. Fire drill was conducted on 7/17/2024. Continued

SUPERVISOR'S NAME: Lisa Rios	TELEPHONE: (916) 969-9685
LICENSING EVALUATOR NAME: Albert Johnson	TELEPHONE: (916) 217-1390
LICENSING EVALUATOR SIGNATURE:	DATE: 08/19/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/19/2024

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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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
	VISIT DATE: 08/19/2024

NARRATIVE

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LPA reviewed twenty (20) client files and five (5) staff files, including criminal record clearances. LPA observed centrally stored medications locked in then medication room. LPA reviewed and compared resident medication vs. resident medication logs. As well as the over the counter medication prescribed by residents primary care physicians. All staff were cleared and associated to the facility. First aid kit was checked and is complete.

Citations given for fire clearance violations with civil penalties assessed.(Photos taken)

Advisories given for South elevator being out of service, and food handlers card for the Sous-Chef (Start date for employment was July 2024). The two gas generators inspected, both inspected gas generators were very low on gas (less then a quarter of a tank). (Photos taken)

Exit interview conducted. A copy of this report was left with the Administrator.

SUPERVISOR'S NAME: Lisa Rios	TELEPHONE: (916) 969-9685
LICENSING EVALUATOR NAME: Albert Johnson	TELEPHONE: (916) 217-1390
LICENSING EVALUATOR SIGNATURE:	DATE: 08/19/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/19/2024

LIC809 (FAS) - (06/04)

Page: 2 of 3

Document Has Been Signed on 08/19/2024 04:51 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: 08/19/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87203

87203 Fire Safety This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation; the facility did not comply with the regulations adopted by the State Fire Marshal. The "Fixed System" or "Ansul System" in the kitchen is scheduled for a semi-annual maintenance and was last serviced on 9/27/2023. This poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 08/20/2024
	Plan of Correction
1 2 3 4	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.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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 Rios	TELEPHONE: (916) 969-9685
LICENSING EVALUATOR NAME: Albert Johnson	TELEPHONE: (916) 217-1390
LICENSING EVALUATOR SIGNATURE:	DATE: 08/19/2024

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/19/2024

LIC809 (FAS) - (06/04)

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