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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 392701057
Report Date: 05/31/2022
Date Signed: 06/28/2022 10:55:14 AM

Document Has Been Signed on 06/28/2022 10:55 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
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: 67DATE:
05/31/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
10:15 AM
MET WITH:Nayda RosalesTIME COMPLETED:
12:45 PM
NARRATIVE
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LPA Johnson arrived at the care facility and met with Nayda R. and Claudia V. to conduct a case management visit into an incident report received on 05/22/2022.

R-1 AWOL'd from the facility on 5/22/2022 at approximately 10:00 AM, R1 has a Paid Personal Assistant/Companion that provides supervision for R1 while R1 is in the community. On 5/22/22 the assistant for R1 was not around or failed to report that they were leaving the facility. As a result, R1 was unaccounted for and was in the community without supervision. Staff members contacted the Assistant and the Administrator to determine if R1 was AWOL. R1 was located by the Paid Personal Assistant/Companion approximately at 10:20AM. R1 returned to the facility with the Paid Personal Assistant/Companion.

According to R1's Physicians report, R1 is not allowed to leave the facility unassisted, However, R1 can leave with an Assistant or a Companion.

LPA provide information for the facility regarding Paid Personal Assistant/Companions and the need to have these individuals finger print cleared and associated to the facility.

Deficiencies were cited on today's date.

Exit interview conducted and appeal rights given.
SUPERVISORS NAME: Stephenie Doub
LICENSING EVALUATOR NAME: Albert Johnson
LICENSING EVALUATOR SIGNATURE: DATE: 05/31/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/31/2022
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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Document Has Been Signed on 06/28/2022 10:55 AM - It Cannot Be Edited


Created By: Albert Johnson On 05/31/2022 at 12:12 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: 05/31/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
06/01/2022
Section Cited
CCR
87464(f)(1)(c)

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Basic Services (c) "Care and supervision" means the facility assumes responsibility for, or provides... assistance with activities of daily living without which the resident’s physical health, mental health, safety, or welfare would be endangered. Assistance includes ...personal care and supervision.
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Licensee will provide a schedule to ensure staffing for residents in care, have all paid assistants finger print cleared and associated to the facility.
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This requirement was not met as evidenced by R1's Companion was not around or failed to report that they were leaving the facility. As a result, R1 was unaccounted for and was in the community without supervision. This poses an immediate health and safety risk and hazard.
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Facility Administrator will ensure ongoing compliance by increased observations for R1 and if needed staffing to meet R1's needs. Written plan due to CCL by 6/1/22.

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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: 05/31/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/31/2022


LIC809 (FAS) - (06/04)
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