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Department of
SOCIAL SERVICES

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 JOSEFACILITY NUMBER:
435202818
ADMINISTRATOR/
DIRECTOR:		PAULA SPANEKFACILITY TYPE:
740
ADDRESS:917 THORNTON WAYTELEPHONE:
(408) 371-7100
CITY:SAN JOSESTATE: CAZIP CODE:
95128
CAPACITY: 92CENSUS: 56DATE:
05/10/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:20 PM
MET WITH:Christopher SchusterTIME VISIT/
INSPECTION COMPLETED:
06:00 PM
NARRATIVE
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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.
SUPERVISORS NAME: Sarah Yip
LICENSING EVALUATOR NAME: Christine Dolores
LICENSING EVALUATOR SIGNATURE: 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


Created By: Christine Dolores On 05/10/2024 at 10:37 AM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 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
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Request Denied
Type A
05/11/2024
Section Cited
CCR
87468.2(a)(4)

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(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:
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Licensee will submit a written plan to address the citation issued to LPA Dolores via email by POC due date.
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Based on interview, record review, and observation the licensee did not ensure resident (R1) was provided a PRN medication within a timely manner and waited about 2 hours before it was dispensed which poses an immediate health, safety, and personal rights risk to persons in care
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Request Denied
Type A
05/11/2024
Section Cited
CCR87466

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The licensee shall ensure that residents are regularly observed for changes in physical, mental, emotional and social functioning and that appropriate assistance is provided when such observation reveals unmet needs. When changes such as unusual weight gains or losses or deterioration of mental ability or a physical health condition are observed, the licensee shall ensure that such changes are documented and brought to the attention of the resident's physician and the resident's responsible person, if any.
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Licensee will submit a written plan to address the citation issued to LPA Dolores via email by POC due date.
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Based on interview, record review and observation the licensee did not ensure to immediately inform resident (R1)'s physician of R1's change of condition on 12/26/2023 which poses an immediate health, safety, and personal rights risk to persons 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 Yip
LICENSING EVALUATOR NAME:Christine Dolores
LICENSING EVALUATOR SIGNATURE:
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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