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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415601091
Report Date: 12/13/2021
Date Signed: 12/13/2021 10:27:33 AM

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 2FACILITY NUMBER:
415601091
ADMINISTRATOR:SORONGON, ESPERANZAFACILITY TYPE:
735
ADDRESS:2498 OAKMONT DRIVETELEPHONE:
(650) 580-3896
CITY:SAN BRUNOSTATE: CAZIP CODE:
94066
CAPACITY:4CENSUS: 0DATE:
12/13/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Administrator, Amy SorongonTIME COMPLETED:
11:00 AM
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On December 13, 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 Administrator, Amy Sorongon and Espie Sorongon. 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. COVID-19 signage are posted throughout the facility such as social distancing, face covering, cough etiquette, and COVID-19 symptoms. According to the Administrator, this facility is only used for isolation purposes when a resident from one of their other facilities (Oakmont Home Corp, Jar Home, and Louvaine Home) tests positive for COVID 19.

LPA observed two bathrooms, both equipped with liquid hand soaps, paper towels, non-skid mats, covered trash bins, and hand-washing signs. There are 4 private bedrooms at the facility, all of which are vacant at this time.

Because there are no residents at this time, there are no medications at the facility. LPA observed locked cabinet where medications will be stored. LPA observed toxins and sharps locked away. A comfortable temperature is maintained. Lighting is sufficient for comfort. First aid kit was observed to be completed. Extra linen was observed to be present at the facility.

Report is reviewed with the Administrator and a copy is provided.

LPA requests for the following documents to be sent by 12/21/21:
-LIC309 Administrative Organization
-LIC308 Designation of Administrative Organization
-LIC500 Personnel Report
-LIC400 Cash Resources
-Administrator Certificate
-LIC610D Emergency Disaster Plan
SUPERVISOR'S NAME: Julio MontesTELEPHONE: (650) 272-7906
LICENSING EVALUATOR NAME: Komal CharitraTELEPHONE: (650) 266-8800
LICENSING EVALUATOR SIGNATURE:

DATE: 12/13/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/13/2021
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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