435202818-5-10-2024-26-AS-CDOS-D5635S-20240510175713

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 435202818
Report Date: 05/10/2024
Date Signed: 05/10/2024 05:57:19 PM

Document Has Been Signed on 05/10/2024 05:57 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 SAN JOSE		FACILITY NUMBER:	435202818
ADMINISTRATOR/ DIRECTOR:	PAULA SPANEK		FACILITY TYPE:	740
ADDRESS:	917 THORNTON WAY		TELEPHONE:	(408) 371-7100
CITY:	SAN JOSE	STATE: CA	ZIP CODE:	95128
CAPACITY: 92	TOTAL ENROLLED CHILDREN: 0	CENSUS: 56	DATE:	05/10/2024
TYPE OF VISIT:	Case Management - Deficiencies	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	01:20 PM
MET WITH:	Christopher Schuster		TIME VISIT/ INSPECTION COMPLETED:	06:00 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	Licensing Program Analysts (LPAs) Christine Dolores and Grace Donato arrived unannounced to conduct case management deficiencies visit due to violations observed during a complaint investigation for control number: 26-AS-20231227155220. LPAs met with Interim Executive Director, Christopher Schuster. On 12/26/2023 resident (R1) began to develop flu-like symptoms and was transferred to the hospital on 12/27/2023. Based on staff interviews, staff stated the observation of R1's change of condition on 12/26/2023. On 12/26/2023, the facility did not notify R1’s physician immediately regarding the change of condition. On 12/26/2023 R1’s responsible party contacted the facility around 6:00PM requesting to administer R1 a PRN medication due to verbalized pain and illness. R1’s responsible party spoke with a staff who stated the medtech on duty was currently on lunch and would relay the request when the medtech returns from lunch. Based on interview, the medtech was notified via voicemail, however, the medtechs are not good at listening to their voicemail right away. Based on record review, R1’s PRN medication was not administered until around 8:00PM, about 2 hours after the PRN medication was verbally requested. Deficiencies were cited per California Code of Regulations, Title 22. See LIC809-D. A civil penalty for repeat violation within a 12-month period is being assessed for the mount of $250. See LIC421FC. This report was reviewed with Interim Executive Director, Christopher Schuster and a copy of the report and appeal rights were provided.

Sarah Yip	TELEPHONE: (408) 324-2131
Christine Dolores	TELEPHONE: (408) 334-8552
	DATE: 05/10/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/10/2024

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 05/10/2024 05:57 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 SAN JOSE	FACILITY NUMBER: 435202818
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 05/10/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Request Denied

Section Cited

(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. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4
	POC Due Date: 05/11/2024
	Plan of Correction
1 2 3 4	Licensee will submit a written plan to address the citation issued to LPA Dolores via email by POC due date.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

Sarah Yip	TELEPHONE: (408) 324-2131
Christine Dolores	TELEPHONE: (408) 334-8552
	DATE: 05/10/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/10/2024

LIC809 (FAS) - (06/04)

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