435202772-7-19-2021-26-AS-ABUI-C53V34-20210719160408

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 435202772
Report Date: 07/16/2021
Date Signed: 07/19/2021 04:04:19 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: 24	DATE:	07/16/2021
TYPE OF VISIT:	Post Licensing	UNANNOUNCED	TIME BEGAN:	10:13 AM
MET WITH:	Kevin Booth		TIME COMPLETED:	05:00 PM

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 07/16/2021 at 10:13 am, Licensing Program Analyst (LPA) Anna Bui conducted an unannounced Post-Licensing visit. LPA met with Interim-Executive Director Kevin Booth. LPA toured the facility beginning with the main entrance. The entrance had a thermometer, hand sanitizer, and sign-in log to document temperature and screening questions. Universal precautions, COVID-19 protocols, and social distancing guidelines were posted throughout the facility. Restrooms had hand soap and paper towels readily available. Hand washing sign was posted at all hand washing stations. Staff and residents were observed wearing a mask and following COVID-19 protocols. Facility observed to have adequate supply of PPE. LPA also reviewed 4 residents files and interviewed 3 residents. Residents files had required documents, including LIC 602 (Physician’s Report), Needs and Services Plan or Pre-Appraisal Assessment, and TB test result. LPA also reviewed 5 staff files and interviewed 3 staff. It was observed that S2’s date of employment was on 05/27/2021, but S2’s fingerprint clearance is still pending. It was also observed that S3’s date of employment was on 05/06/2021; however, S3 is not associated to the facility. -Continued, see 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: 07/16/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/16/2021

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: 07/16/2021

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LPA also reviewed facility’s staff association list on Guardian, the Department’s background check system. Guardian shows that as of 07/16/2021, S2’s fingerprint clearance is still in process, and S3 is cleared but not associated to the facility.

A deficiency was cited during today’s visit, see LIC 809-D.

A civil penalty is being assessed for the amount of $500 ($100 per day x 5 days = $500), for staff (S2) working at the facility without fingerprint clearance. Another civil penalty is being assessed for the amount of $500 ($100 per day x 5 days = $500), for staff (S3) working at the facility without being associated to the facility. Please see LIC 421BG.

Exit interview was conducted with Interim-Executive Director Kevin Booth. This report, LIC 809-D, civil penalty, plan of correction, and appeal rights were discussed with Interim-Executive Director Kevin Booth, and copies were provided.

SUPERVISOR'S NAME: Sarah Yip	TELEPHONE: (408) 324-2131
LICENSING EVALUATOR NAME: Anna Bui	TELEPHONE: 650-269-7419
LICENSING EVALUATOR SIGNATURE:	DATE: 07/16/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/16/2021

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
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 07/16/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87355(e)(1)

Criminal Record Clearance

(e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility: (1) Obtain a California clearance or a criminal record exemption as required by the Department or This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above in 1 (S2) out of 5 staff, which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 07/17/2021
	Plan of Correction
1 2 3 4	S2 left the facility and will not return until S2 is fingerprint cleared. Licensee/Administrator agreed to develop a plan in writing to ensure all new staff are fingerprint cleared and associated with the facility prior to working and will submit the plan to LPA by the POC due date.

Type A

Section Cited

CCR

87355(e)(2)

Criminal Record Clearance

(e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility: (2) Request a transfer of a criminal record clearance as specified in Section 87355(c) or This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above in 1 (S3) out of 5 staff, which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 07/17/2021
	Plan of Correction
1 2 3 4	S3 left the facility and will not return until S3 is associated to the facility. Licensee/Administrator agreed to develop a plan in writing to ensure all new staff are fingerprint cleared and associated with the facility prior to working and will submit the plan to LPA by the POC due date.

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: Sarah Yip	TELEPHONE: (408) 324-2131
LICENSING EVALUATOR NAME: Anna Bui	TELEPHONE: 650-269-7419
LICENSING EVALUATOR SIGNATURE:	DATE: 07/16/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/16/2021

LIC809 (FAS) - (06/04)

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