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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415601074
Report Date: 12/01/2021
Date Signed: 12/01/2021 03:15:50 PM

Document Has Been Signed on 12/01/2021 03:15 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, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
FACILITY NAME:OAKMONT HOME CORPFACILITY NUMBER:
415601074
ADMINISTRATOR:SORONGON, AMYFACILITY TYPE:
735
ADDRESS:2961 OAKMONT DRIVETELEPHONE:
(650) 636-4017
CITY:SAN BRUNOSTATE: CAZIP CODE:
94066
CAPACITY: 4CENSUS: 4DATE:
12/01/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:15 PM
MET WITH:Administrator, Amy SorongonTIME COMPLETED:
01:30 PM
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On December 1, 2021, Licensing Program Analyst (LPA) Komal Charitra, conducted an unannounced annual inspection. Upon arrival, LPA observed COVID-19 signage on the front door. LPA met with Caregiver, Myra Alim, and Administrator, Amy Sorongon joined shortly thereafter. LPA Charitra explained the purpose of the visit and was screened at the designated entrance.

LPA toured the facility and grounds. No accessible bodies of water or fire safety hazards observed. Infection control practices are reviewed: entry procedures, resident and staff daily monitoring records, visitor screening log, and 30-day PPE supply. Caregiver was able to provide screening log documentation for residents, visitors, and staff. COVID-19 signage are posted throughout the facility such as social distancing, face covering, cough etiquette, and COVID-19 symptoms.

LPA observed two bathrooms, both equipped with liquid hand soap, paper-towels, non-skid mats and a covered trash bin. There are 4 private bedrooms at the facility, all of which are occupied at this time. LPA toured the kitchen and observed sufficient amount of perishable and non-perishable foods. LPA advised Caregiver to not keep hand-towels in the kitchen.

Medications, toxins and sharps are stored appropriately and inaccessible to residents, and a comfortable temperature is maintained. Lighting is sufficient for comfort. First aid kit was observed to be completed.

Report is reviewed with the Administrator and a copy is provided.
SUPERVISORS NAME: Julio Montes
LICENSING EVALUATOR NAME: Komal Charitra
LICENSING EVALUATOR SIGNATURE: DATE: 12/01/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/01/2021
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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