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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202772
Report Date: 11/09/2022
Date Signed: 11/09/2022 12:02:53 PM


Document Has Been Signed on 11/09/2022 12:02 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
CENTRAL COAST CR/RES, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131



FACILITY NAME:OAKMONT OF SILVER CREEKFACILITY NUMBER:
435202772
ADMINISTRATOR:BAGHERI, TAYEBEHFACILITY TYPE:
740
ADDRESS:3544 SAN FELIPE ROADTELEPHONE:
(669) 288-5000
CITY:SAN JOSESTATE: CAZIP CODE:
95135
CAPACITY:148CENSUS: DATE:
11/09/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
09:32 AM
MET WITH:Sam FayeTIME COMPLETED:
12:06 PM
NARRATIVE
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Licensing Program Analyst Ryker Heberle (LPA) arrived at the facility unannounced to conduct a case management visit regarding an incident of elopement by a resident (R1) from the facility. LPA met with facility Administrator Sam Faye (Admin).

Admin was able to determine that at around 6:00pm-6:30pm, paramedics and firefighters arrived at the facility to assist a different resident in receiving medical care and being transported to the hospital. Admin believes that while the paramedics were entering and exiting the facility, the resident slipped out beyond the delayed egress doors. R1 was then discovered to be missing at 10:00pm. R1 was brought back to the facility by family at 2:00am the following morning.

Review of the egress door records by the administrator indicate that there was no instance of the egress alarm being triggered at the date and time of the incident, and noted that entry and exit through use of a code would not log an incident in the report. LPA tested the delayed egress doors and observed them to be functioning properly. Review of facility exterior camera footage showed the resident leaving the facility through the side door at 6:06pm. R1 was not observed by facility staff between the hours of 06:00pm and 2:00am, No staff observed the elopement. Review of R1's care plan indicates that R1 requires visual check in two times per shift. It is undetermined when the two evening shift check-ins occurred on the day of the incident.

Deficiency cited. See 809-D. This report was reviewed with facility Administrator Sam Faye and a copy of the signed report was provided.
SUPERVISOR'S NAME: Sarah YipTELEPHONE: (408) 324-2131
LICENSING EVALUATOR NAME: Ryker HeberleTELEPHONE: 714-328-5152
LICENSING EVALUATOR SIGNATURE:
DATE: 11/09/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/09/2022
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 11/09/2022 12:02 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
CENTRAL COAST CR/RES, 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: 11/09/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
11/10/2022
Section Cited

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Care of Persons with Dementia - (k) The following... must be met for the licensee to utilize delayed egres devices... (8) Delayed egress devices shall not substitute for trained staff... to meet the care and supervision needs of all residents... This requirement was not met as evidenced by:
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Based on records review and interviews, the facility did not adequately supervise R1, resulting in elopement. This presented an immediate risk to the health and safety of residents 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: Sarah YipTELEPHONE: (408) 324-2131
LICENSING EVALUATOR NAME: Ryker HeberleTELEPHONE: 714-328-5152
LICENSING EVALUATOR SIGNATURE:
DATE: 11/09/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/09/2022
LIC809 (FAS) - (06/04)
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