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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202737
Report Date: 03/24/2022
Date Signed: 03/24/2022 05:59:56 PM


Document Has Been Signed on 03/24/2022 05:59 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, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131



FACILITY NAME:OAKMONT OF SAN JOSEFACILITY NUMBER:
435202737
ADMINISTRATOR:FLAVIO SILVAFACILITY TYPE:
740
ADDRESS:917 THORNTON WAYTELEPHONE:
(408) 371-7100
CITY:SAN JOSESTATE: CAZIP CODE:
95128
CAPACITY:92CENSUS: 56DATE:
03/24/2022
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Flavio SilvaTIME COMPLETED:
06:00 PM
NARRATIVE
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Licensing Program Analyst (LPA) Christine Dolores arrived at the facility unannounced to conduct the pre-licensing visit for facility #435202818. LPA met with Executive Director, Flavio Silva.

During visit, LPA reviewed six residents centrally stored medication records with resident medications. At 11:00 a.m., LPA and staff observed a resident's medication to be expired on 08/2021. Staff states residents medication are given once daily and was administered medication from 8/2021 - current. LPA observed resident's Medication Administration Record (MAR) and observed daily administration for March 2022. Leadership was informed immediately. Medication was removed, family member and doctor was informed, and new medication was bought the same day.

At 12:30 p.m., LPA observed facility's non-perishable supplies in the basement area. LPA observed expired non-perishables to include three large cans of pasta, a case full of canned soup, and a large bottle of apple juice. The expired items were removed the same day and the facility will be replenishing additional non-perishable supplies by next shipment of 03/26/2022.

At 3:30 p.m., LPA reviewed two staff personnel records. LPA did not observe the staff files to consist of 1st Aid Certification, Health Screening, TB Information, and Criminal Record Statement. Facility has a plan in place to provide first aid certification for staff who are not up-to-date.

Deficiency cited today per California Code of Regulation, Title 22. Technical Violations issued. See LIC809D.

This report was reviewed with Flavio Silva and a copy of the report and appeal rights were provided.
SUPERVISOR'S NAME: Jackie JinTELEPHONE: (714) 319-3786
LICENSING EVALUATOR NAME: Christine DoloresTELEPHONE: (408) 334-8552
LICENSING EVALUATOR SIGNATURE:
DATE: 03/24/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/24/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2


Document Has Been Signed on 03/24/2022 05:59 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131


FACILITY NAME: OAKMONT OF SAN JOSE
FACILITY NUMBER: 435202737

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/24/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
03/25/2022
Section Cited

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(i) Prescription medications which are not taken with the resident upon termination of services, not returned to the issuing pharmacy, nor retained in the facility as ordered by the resident’s physician...are otherwise to be disposed of shall be destroyed in the facility by the facility administrator and one other adult who is not a resident... This requirement is not met as evidence by:
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Based on interview, observation, and record review the resident was being administered expired medication once daily from the expiration date of 08/2021 to current day which poses an immediate health, safety, and personal rights risk to persons in care.
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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: Jackie JinTELEPHONE: (714) 319-3786
LICENSING EVALUATOR NAME: Christine DoloresTELEPHONE: (408) 334-8552
LICENSING EVALUATOR SIGNATURE:
DATE: 03/24/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/24/2022
LIC809 (FAS) - (06/04)
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