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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 392701272
Report Date: 04/26/2024
Date Signed: 04/26/2024 01:44:34 PM


Document Has Been Signed on 04/26/2024 01:44 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 LODIFACILITY NUMBER:
392701272
ADMINISTRATOR:ARMSTRONG, ANDREAFACILITY TYPE:
740
ADDRESS:2905 REYNOLDS RANCH PARKWAYTELEPHONE:
(209) 310-1512
CITY:LODISTATE: CAZIP CODE:
95240
CAPACITY:136CENSUS: 96DATE:
04/26/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
01:27 PM
MET WITH:Andrea ArmstrongTIME COMPLETED:
02:00 PM
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An unannounced case management visit was conducted by the Licensing Program Analyst (LPA) Avelina Martinez on 04/26/2024 at 1:20 PM. LPA Martinez met with the facility administrator Andrea Armstrong and explain the purpose of the visit.

The purpose of the visit is to follow up on an incident reports received on February 07, 2024 and February 24, 2024 . Both incidents involved falls with injuries. LPA Martinez requested copies of the following documents for resident 1 and resident 2: Admission Agreement, Physician Report LIC 602, and Needs and service plan, reassessments, pre-placement/assessment, and hospital discharge summary reports. The requested documents should be emailed to LPA Martinez by 04/20/2024 5:00 PM. LPA Martinez will follow up on the incidents at a later date and time.

No, deficiencies were cited at this time. An exit interview was conducted, and a copy of this report was provided to the facility.

SUPERVISOR'S NAME: Liza KingTELEPHONE: (650) 676-0442
LICENSING EVALUATOR NAME: Avelina MartinezTELEPHONE: (916) 431-8935
LICENSING EVALUATOR SIGNATURE:
DATE: 04/26/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/26/2024
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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