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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202898
Report Date: 10/06/2023
Date Signed: 10/06/2023 05:00:19 PM


Document Has Been Signed on 10/06/2023 05:00 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:
435202898
ADMINISTRATOR:DIAL, JAMESFACILITY TYPE:
740
ADDRESS:3544 SAN FELIPE ROADTELEPHONE:
(669) 200-2443
CITY:SAN JOSESTATE: CAZIP CODE:
95135
CAPACITY:148CENSUS: 70DATE:
10/06/2023
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
11:15 AM
MET WITH:Mary Ann BangsalTIME COMPLETED:
12:02 PM
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Licensing Program Analyst (LPA) Steve Chang conducted an unannounced pre-licensing inspection visit for changing ownership of the facility, and met with Business Office Director Mary Ann Bangsal (MB) and Memory Care Director Judith Diaz (JD)..

LPA checked 5 resident files and 5 staff files with MB and JD.

During visit, LPA toured the facility with Maintenance Director Jaime Martinez (JM) to include front desk, the living room, reading room, coffee area, activity room, work room, break room, fitness room, movie theater, restrooms, conference rooms, medications rooms, dinning room, kitchen, laundry room, memory care unit bedrooms, assisted living unit bedrooms and court yard. All fire exits and court yard were free and clear of obstruction. Facility was equipped with fire alarm system and carbon monoxide detectors. JM tested the carbon monoxide detectors, and they were working fine. Facility temperature maintained at 75 degrees Fahrenheit. Hot water was measured at 106 degree Fahrenheit. Fire extinguishers were serviced on 12/23/2022.

Two day perishable food supplies and 7 days nonperishable food supplies were observed sufficient.
Sharp objects, disinfectants, and chemicals observed locked. Medications rooms and medication carts were observed locked.

Component III was conducted with MB.

No citations were noted today. Exit interview was conducted with MB. The report was provided to MB for signature. A copy of the report was provided to MB.
SUPERVISOR'S NAME: Romeo ManzanoTELEPHONE: (408) 324-2112
LICENSING EVALUATOR NAME: Chihhsien ChangTELEPHONE: (408) 904-9843
LICENSING EVALUATOR SIGNATURE:
DATE: 10/06/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/06/2023
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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