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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202818
Report Date: 03/24/2022
Date Signed: 03/24/2022 05:59:01 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:
435202818
ADMINISTRATOR:SILVA, FLAVIOFACILITY TYPE:
740
ADDRESS:917 THORNTON WAYTELEPHONE:
(408) 371-7100
CITY:SAN JOSESTATE: CAZIP CODE:
95128
CAPACITY:92CENSUS: 56DATE:
03/24/2022
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Flavio SilvaTIME COMPLETED:
06:00 PM
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Licensing Program Analyst (LPA) Christine Dolores arrived unannounced to conduct a pre-licensing visit and met with Executive Director, Flavio Silva.

There is currently residents living at the facility. The facility has three floors - floors two and three consist of assisted living, and floor one consist of memory care. The facility has an approved fire clearance for 92 non ambulatory in which 8 may be bedridden.

LPA toured the facility inside and outside including the apartments, bathrooms, kitchen, and common areas. Resident apartments were equipped with proper furniture and lighting. Resident apartment temperature was maintained between 75 to 78 degrees Fahrenheit. Bathrooms are equipped with grab bars, nonskid floors, hygiene supplies, and toiletry. Facility is equipped with cups, plates, utensils, and cooking supplies. Hot water temperature was measured between 105.0 to 111.4 degrees Fahrenheit in the common bathrooms.

The facility has designated medication rooms with locked medication cabinets. LPA reviewed centrally stored medication records with residents medications. LPA observed first aid kit with the following supplies: bandages, scissors, tweezers, and thermometer.

LPA observed supplies of perishable and non-perishable supplies. Refrigerator temperature was maintained at 35 degrees Fahrenheit. Freezer temperature was maintained at 0 degrees Fahrenheit.

See LIC809C for more information.
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)
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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 SAN JOSE
FACILITY NUMBER: 435202818
VISIT DATE: 03/24/2022
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Facility is equipped with smoke detectors, carbon monoxide detectors, and fire extinguishers. Hallway and passageways were observed free of obstruction.

During today's visit, LPA observed the following posters: personal rights, if you see something say something, ombudsmen, resident right to counsel, and activities/events calendar.

LPA reviewed 6 resident records and 2 staff records. Resident files all consist of Admission Agreement, Medical Assessment with TB Information, Consent Forms, Care Plans, Safeguard for Personal Properties and Valuables, and Personal Rights. LPA did not observe the staff files to consist of 1st Aid Certification, Health Screening, TB Information, and Criminal Record Statement.

A deficiency was cited and technical violation was issued during this pre-licensing inspection. See LIC809D for facility number #435202737.

LPA observed the facility is not ready to be licensed. LPA will follow-up with another visit once deficiency and technical violations are corrected.

This report was reviewed with Flavio Silva and a copy of this report 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
LIC809 (FAS) - (06/04)
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