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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415601091
Report Date: 06/07/2023
Date Signed: 06/07/2023 09:08:15 PM

Document Has Been Signed on 06/07/2023 09:08 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
SF COASTAL AC/SC, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
FACILITY NAME:OAKMONT HOME 2FACILITY NUMBER:
415601091
ADMINISTRATOR:CHAN, JEVELYNFACILITY TYPE:
735
ADDRESS:2498 OAKMONT DRIVETELEPHONE:
(650) 580-3896
CITY:SAN BRUNOSTATE: CAZIP CODE:
94066
CAPACITY: 4CENSUS: 3DATE:
06/07/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
12:00 PM
MET WITH:Licensed Staff Chona LaranangTIME COMPLETED:
01:45 PM
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On 6/7/2023, Licensing Program Analyst (LPA) Murial Han conducted an unannounced case management visit to follow-up on an incident that was reported to CCL. LPA met with Licensed Nurse Chona Laranang and explained the purpose of the visit. Licensed Nurse contacted the assistant. administrator, Bill Fajardo who arrived and assisted with the visit.

Facility report that on 5/10/2023, staff #1(S1) witnessed staff #2 (S2) hitting/slapping resident #1 (R1). After the incident was reported, a skin assessment was conducted for R1 by a Licensed Nurse and no injuries were noted. In addition, facility started the investigation and placed S2 on administrative leave during the investigation.

During today's visit, LPA reviewed facility documents and interviewed facility staff.

According to the Licensed Nurse there is no change in R1's well-being, and activities of daily living since the alleged incident was reported and facility continued to perform skin checks for S1 on a daily basis.

According to the assistant administrator, after the facility was informed of the alleged incident, the facility reported it to varies departments and R1's responsible parties, started the investigation process, conducted zoom meetings with varies parties and provided in-services to facility staff.

No deficiency is cited.

This report is reviewed and discussed with assistant administrator. Due to technical difficult, a copy of the report will be provided electronically.
SUPERVISORS NAME: Cara Smith
LICENSING EVALUATOR NAME: Murial Han
LICENSING EVALUATOR SIGNATURE: DATE: 06/07/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/07/2023
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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