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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415601114
Report Date: 10/31/2024
Date Signed: 10/31/2024 02:24:43 PM

Document Has Been Signed on 10/31/2024 02:24 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
SAN BRUNO RO, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
FACILITY NAME:OAKMONT OF REDWOOD CITYFACILITY NUMBER:
415601114
ADMINISTRATOR/
DIRECTOR:
SIOBAHN SURRACOFACILITY TYPE:
740
ADDRESS:1 EAST SELBY LANETELEPHONE:
(650) 885-7992
CITY:REDWOOD CITYSTATE: CAZIP CODE:
94063
CAPACITY: 127CENSUS: 55DATE:
10/31/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:30 AM
MET WITH:Administrator, Siobahn SurracoTIME VISIT/
INSPECTION COMPLETED:
02:35 PM
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On October 31, 2024, Licensing Program Analyst (LPA) Komal Charitra conducted an unannounced annual inspection. LPA met with Administrator, Siobhan Surraco and explained the purpose of the visit.

LPA toured facility and grounds. No accessible bodies of water or fire safety hazards observed. This is a 3 story facility with Memory Care on the first and half of the second floor and Assisted Living on the other half of the second floor and third floor. LPA toured the facility including but not limited to a random sample of resident rooms on each floor, common areas, and kitchen area. LPA observed some residents doing activities with staff or watching television. A comfortable temperature is maintained in the facility and lighting is sufficient for comfort. Hot water temperature measured between 111-119 degrees F throughout the facility. Overall facility was in clean, odor-free and free from any tripping hazards. Resident rooms and bathrooms observed had all required furnishings, and grab bars and built-in non-skid mats in each bathroom.

LPA toured kitchen and observed 2 days for perishables and and 7 days non-perishable. Medications, sharps and chemicals were locked and inaccessible to residents. Emergency drill are being conducted and logged every 3 months. Carbon monoxide monitors are working properly. First aid kits were observed present and complete.

Five resident records and five staff records were reviewed. Resident records are updated, complete and signed. Staff records are complete, with training logs that have met the basic requirement. Medication review was done, and all medications are accounted for, and centrally stored medication records are updated.

The following documents are requested to be submitted to CCL by 11/7/24:
-LIC308 Designation of Administrative Responsibility
-LIC610E Emergency Disaster Plan
-LIC500 Personnel Report

No deficiencies are cited at this time. Report is reviewed with Administrator and copy is provided.
SUPERVISORS NAME: April Cowan
LICENSING EVALUATOR NAME: Komal Charitra
LICENSING EVALUATOR SIGNATURE: DATE: 10/31/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/31/2024
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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