<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202772
Report Date: 08/18/2022
Date Signed: 08/18/2022 04:34:10 PM


Document Has Been Signed on 08/18/2022 04:34 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 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: 58DATE:
08/18/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
08:50 AM
MET WITH:Tina BagheriTIME COMPLETED:
10:05 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
Licensing Program Analyst (LPA) Steve Chang conducted an unannounced Case Management visit, and met with Executive Director (ED) Tina Bagheri.

On 8/9/2022, the Department received a death report regarding R1.

Based on the death report, on 8/9/2022, R1 was sent to hospital due to a fall.

LPA requested R1's physician report, Appraisal Needs and Service plan, and incident report. LPA interviewed ED, and a staff Emma Williams (S1).

Based on the record reviewed and the interviews conducted, the Department determined that there was lack of supervision for R1 when R1 walked without the walker. R1's care plan noted R1 requires supervision if R1 ambulate without the walker. No staff was supervising R1 when R1 was walking without walker which result in R1 falling..

A deficiency noted today. See LIC809-D. Exit interview was conducted with ED This report and LIC809-D were provided to ED for record.
SUPERVISOR'S NAME: Romeo ManzanoTELEPHONE: (408) 324-2112
LICENSING EVALUATOR NAME: Chihhsien ChangTELEPHONE: (408) 904-9843
LICENSING EVALUATOR SIGNATURE:
DATE: 08/16/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/16/2022
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 08/18/2022 04:34 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 SILVER CREEK
FACILITY NUMBER: 435202772

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/18/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Deficiency Dismissed
Type A
08/18/2022
Section Cited

1
2
3
4
5
6
7
Additional Personal Rights of Residents in Privately Operated Facilities (a) In addition to the rights listed in Section 87468.1, Personal Rights of Residents in All Facilities, residents in privately operated residential care facilities for the elderly shall have all of the following personal rights: (4) To care, supervision, and services that meet their individual needs and are delivered by staff that are sufficient in numbers, qualifications, and competency to meet their needs.
8
9
10
11
12
13
14
This requirement was not met as evidenced by:
Based on interviews, and records review,
R1 was not supervised when R1 was walking without walker result in R1 falling. This posed an immediate risk to the health and safety of resident in care.
8
9
10
11
12
13
14

1
2
3
4
5
6
7

1
2
3
4
5
6
7
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: Romeo ManzanoTELEPHONE: (408) 324-2112
LICENSING EVALUATOR NAME: Chihhsien ChangTELEPHONE: (408) 904-9843
LICENSING EVALUATOR SIGNATURE:
DATE: 08/18/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/18/2022
LIC809 (FAS) - (06/04)
Page: 2 of 2