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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 392701057
Report Date: 01/03/2023
Date Signed: 01/19/2023 12:32:03 PM


Document Has Been Signed on 01/19/2023 12:32 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: 55DATE:
01/03/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
02:09 PM
MET WITH:P. HolguinTIME COMPLETED:
03:45 PM
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LPA Johnson made a case management visit regarding case closure for a back ground check on Per ID: 7500092127 Exemption Denial Background Check ID: 6611500
Records indicate that the above referenced individual did not pass an exemption or did not submit all the information within the specified time frame.

Identified individuals shall not be allowed on the facility premises nor have any contact with clients unless a criminal record clearance is obtained.

There were no deficiencies during today’s visit
SUPERVISOR'S NAME: Stephenie DoubTELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Albert JohnsonTELEPHONE: (916) 217-1390
LICENSING EVALUATOR SIGNATURE:
DATE: 01/03/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/03/2023
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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