435202772-5-4-2021-26-AS-ABUI-C2PUXC-20210504155803

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 435202772
Report Date: 05/04/2021
Date Signed: 05/04/2021 03:58:37 PM

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 SILVER CREEK		FACILITY NUMBER:	435202772
ADMINISTRATOR:	CABUENA, JAIRUS		FACILITY TYPE:	740
ADDRESS:	3544 SAN FELIPE ROAD		TELEPHONE:	(669) 288-5000
CITY:	SAN JOSE	STATE: CA	ZIP CODE:	95135
CAPACITY:	148	CENSUS:	DATE:	05/04/2021
TYPE OF VISIT:	Prelicensing	ANNOUNCED	TIME BEGAN:	09:01 AM
MET WITH:	Jairus "Jett" Cabuena		TIME COMPLETED:	11:30 AM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	On 05/04/2021 at 9:01 am, Licensing Program Analyst (LPA) Anna Bui conducted an announced Pre-licensing Inspection visit. Due to COVID-19 health pandemic, LPA met with Executive Director Jarius “Jett” Cabuena and Vice President of Operations Jason Engelhorn via Facetime. LPA was accompanied by the Administrator and Vice President of Operations during the entire tour of the facility. Facility has 2 floors, with Memory Care and Bedridden rooms located on the 1^st floor. Memory Care is equipped with an Auditory Signal System and exits have operational delayed egress doors. Apartment units in Assisted Living and Memory Care were observed adequately clean and in good repair. Bathrooms and showers were equipped with grab bars and non-skid flooring. Hot water temperature was taken in 5 residents’ apartments (Room 183, 174, 217, 213, 203), range between 108.7-110.9 degrees Fahrenheit. All major hallways and indoor and outdoor passage ways were observed well-lit and free of obstruction. First aid kid was observed complete with all necessary supplies. Facility has a laundry unit with laundry supplies available. Disinfectant and cleaning solutions were observed locked and inaccessible to residents. No pools were observed. There is a water fountain, however, it is inaccessible to the residents. Continued on LIC 809-C.

SUPERVISOR'S NAME: Sarah Yip	TELEPHONE: (408) 324-2131
LICENSING EVALUATOR NAME: Anna Bui	TELEPHONE: 650-269-7419
LICENSING EVALUATOR SIGNATURE:	DATE: 05/04/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/04/2021

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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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 SILVER CREEK	FACILITY NUMBER: 435202772
	VISIT DATE: 05/04/2021

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Fire clearance is approved for 140 non-ambulatory residents and 8 bedridden residents. Facility is equipped with an automatic sprinkler system. Smoke and carbon monoxide detectors were observed and operational. Fire extinguishers were observed throughout the facility and was last serviced on December 2020. Stairwells were free of obstruction and equipped with emergency evacuation chairs.

Kitchen area was observed clean and in compliance. At least 2 days worth of perishables and 7 days worth of nonperishable were observed. Refrigerator temperature is maintained at 36 degrees Fahrenheit and freezer temperature is maintained at -4 degrees Fahrenheit.

COMP III is waived, as Jarius “Jett” Cabuena, Executive Director, has been an Administrator for 2 years and received COMP III orientation in 2019.

No issues were noted during this Pre-Licensing inspection. LPA observed the facility is ready to be licensed. However, this report will be submitted to the Central Applications Bureau (CAB) and a final review of the application will be conducted. This facility is not yet licensed and is subject to final approval by CAB. Additional requirements may still be needed.

This report was reviewed with Jarius “Jett” Cabuena, Executive Director, and a copy of this report was emailed on 05/04/2021 to Jarius “Jett” Cabuena, Executive Director, and Jason Engelhorn, Vice President of Operations, for signature.

SUPERVISOR'S NAME: Sarah Yip	TELEPHONE: (408) 324-2131
LICENSING EVALUATOR NAME: Anna Bui	TELEPHONE: 650-269-7419
LICENSING EVALUATOR SIGNATURE:	DATE: 05/04/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/04/2021

LIC809 (FAS) - (06/04)

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