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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415600990
Report Date: 10/31/2023
Date Signed: 10/31/2023 11:21:43 AM


Document Has Been Signed on 10/31/2023 11:21 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
SF COASTAL AC/SC, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066



FACILITY NAME:OAKMONT OF BURLINGAMEFACILITY NUMBER:
415600990
ADMINISTRATOR:JEFF SUMABATFACILITY TYPE:
740
ADDRESS:1818 TROUSDALE DRTELEPHONE:
(650) 692-2805
CITY:BURLINGAMESTATE: CAZIP CODE:
94010
CAPACITY:97CENSUS: 74DATE:
10/31/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
09:15 AM
MET WITH:Administrator, Jeff SumabatTIME COMPLETED:
11:35 AM
NARRATIVE
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On October 31, 2023, Licensing Program Analyst (LPA) Komal Charitra conducted an unannounced case-management visit in relation to complaint #: 14-AS-20230327113531. LPA met with Administrator, Jeff Sumabat and explained the purpose of the visit.

During the complaint investigation (complaint control #14-AS-20230327113531), LPA requested for Resident 1's (R1's) file to review, however according to facility administrator and staff, R1's file was no longer at the facility. It was indicated that when there was a Change of Management, from Sunrise to Oakmont, all files from the time were sent to Sunrise Management Company. Nevertheless, R1's resident records were not available to inspect during the complaint investigation.

Deficiencies of the California Code of Regulations, Title, 22 cited on the LIC9099-D. Failure to correct the deficiencies may result in civil penalties.

Report is reviewed with Administrator, Jeff Sumabat and a copy is provided with appeal rights.
SUPERVISOR'S NAME: Cara SmithTELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Komal CharitraTELEPHONE: (650) 266-8800
LICENSING EVALUATOR SIGNATURE:
DATE: 10/31/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/31/2023
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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Document Has Been Signed on 10/31/2023 11:21 AM - 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
SF COASTAL AC/SC, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066


FACILITY NAME: OAKMONT OF BURLINGAME
FACILITY NUMBER: 415600990

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/31/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
11/07/2023
Section Cited
CCR
87506(e)

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87506 Resident Records: (e) Original records or photographic reproductions shall be retained for a minimum of three (3) years following termination of service to the resident.

Violation of this regulation is not met as evidenced by:
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Licensee/Administrator to submit a plan in writing describing how facility will ensure 3 years of documents are maintained at the facility for inspection
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Based on interviews, R1's file was not available to LPA for inspection as R1's file is no longer at the facility due to the change of management.
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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: Cara SmithTELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Komal CharitraTELEPHONE: (650) 266-8800
LICENSING EVALUATOR SIGNATURE:
DATE: 10/31/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/31/2023
LIC809 (FAS) - (06/04)
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