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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415601091
Report Date: 06/13/2024
Date Signed: 06/14/2024 09:27:01 AM

Document Has Been Signed on 06/14/2024 09:27 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
SAN BRUNO RO, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
FACILITY NAME:OAKMONT HOME 2FACILITY NUMBER:
415601091
ADMINISTRATOR/
DIRECTOR:		BILL FAJARDOFACILITY TYPE:
735
ADDRESS:2498 OAKMONT DRIVETELEPHONE:
(650) 580-3896
CITY:SAN BRUNOSTATE: CAZIP CODE:
94066
CAPACITY: 4CENSUS: 3DATE:
06/13/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:15 PM
MET WITH:Administrator, Bill FajardoTIME VISIT/
INSPECTION COMPLETED:
03:40 PM
NARRATIVE
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On June 13, 2024, Licensing Program Analyst(LPA) Murial Han conducted an unannounced annual inspection. LPA was greeted by the administrator, Bill Fajardo. LPA explained the purpose of the visit.

LPA toured facility and grounds. No accessible bodies of water or fire safety hazards observed. LPA toured the facility inside and outside including all of resident rooms, common areas, and kitchen area. The indoor and outdoor passageways were free of obstruction. Facility is clean and odor-free. Comfortable temperature is maintained and lighting is sufficient for comfort.

LPA observed four private resident rooms. Rooms were spacious and included all required furnishings. Two full bathrooms were observed to be clean; equipped with paper towels, soap, grab bars, and non-skid mats. Extra linen was present.

LPA observed medications, toxins and sharps were locked and inaccessible to residents. 2 days for perishables and & 7 days non-perishable were observed to be present.

Facility is equipped with smoke detectors and carbon monoxide detectors. Fire extinguishers were checked. Fire drill records were reviewed. Facility exits are equipped with audible alarms.

A review of (3) resident files was conducted and noted on the LIC 858.
A review of (4) staff files was conducted and noted on the LIC 859.

Based on observation, deficiency is cited under California Code of Regulations, Title, 22 cited on the LIC 809D. Failure to correct the deficiencies may result in civil penalties. .

This report is reviewed and discussed with administrator. A copy of this report and the appeal rights were provided.
SUPERVISORS NAME: April Cowan
LICENSING EVALUATOR NAME: Murial Han
LICENSING EVALUATOR SIGNATURE: DATE: 06/13/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/13/2024
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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Document Has Been Signed on 06/14/2024 09:27 AM - It Cannot Be Edited


Created By: Murial Han On 06/13/2024 at 02:50 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066

FACILITY NAME: OAKMONT HOME 2
FACILITY NUMBER: 415601091

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/13/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80072(a)(8)(B)
Personal Rights
(B) A written order from the client's physician indicating the need for the postural support shall be maintained in the client's record. The licensing agency shall be authorized to require additional documentation if needed to verify the order.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, record review and interview,the licensee did not comply with the section cited above as LPA observed 3 out of 3 resident beds have a postual support device- half/quarter bedrails without a physician's order which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/20/2024
Plan of Correction
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The administrator will develop a plan to ensure compliance and provide a copy of the plan to CCL by 6/20/2024.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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:April Cowan
LICENSING EVALUATOR NAME:Murial Han
LICENSING EVALUATOR SIGNATURE:
DATE: 06/13/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/13/2024


LIC809 (FAS) - (06/04)
Page: 2 of 3
Document Has Been Signed on 06/14/2024 09:27 AM - It Cannot Be Edited


Created By: Murial Han On 06/13/2024 at 03:11 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066

FACILITY NAME: OAKMONT HOME 2
FACILITY NUMBER: 415601091

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/13/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80075(b)(6)


This requirement is not met as evidenced by:80075 Health Related Services
Deficient Practice Statement
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Based on observation, record review, and interview, the licensee did not comply with the section cited above as the facility did not have any records/documentation to proof that physician's were contacted prior to administering PRN medications for 3 residents which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 06/14/2024
Plan of Correction
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The Administrator/Licensee will develop a plan to enusre compliance and submitted it to CCL by 6/14/2024.
Section Cited
Deficient Practice Statement
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3
4
POC Due Date:
Plan of Correction
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2
3
4
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:April Cowan
LICENSING EVALUATOR NAME:Murial Han
LICENSING EVALUATOR SIGNATURE:
DATE: 06/13/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/13/2024


LIC809 (FAS) - (06/04)
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