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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202898
Report Date: 10/18/2024
Date Signed: 10/18/2024 11:39:59 AM

Document Has Been Signed on 10/18/2024 11:39 AM - 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 SILVER CREEKFACILITY NUMBER:
435202898
ADMINISTRATOR/
DIRECTOR:		DIAL, JAMESFACILITY TYPE:
740
ADDRESS:3544 SAN FELIPE ROADTELEPHONE:
(669) 200-2443
CITY:SAN JOSESTATE: CAZIP CODE:
95135
CAPACITY: 148CENSUS: 74DATE:
10/18/2024
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:00 AM
MET WITH:Mary Ann Bangsal - Business Office DirectorTIME VISIT/
INSPECTION COMPLETED:
12:00 PM
NARRATIVE
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On 10/18/2024, Licensing Program Analysts (LPAs) Maria (Mita) Partoza and Marcela Yanez conducted an unannounced Case Management-Inspection visit to deliver an immediate exclusion order regarding staff (S1) and met with Mary Ann Bangsal, Business Office Director (BOD). Executive Director/Administrator (ED/ADM) Holly Suiter was in training at the time of the visit was not available.

On 10/8/24, the Department conducted an initial visit to investigate the reported incident involving physical abuse to resident (R1).Staff 1 (S1) employment was terminated immediately after the incident happened to R1 which was on 10/3/24.

LPAs provided a letter "Order to Licensee/Facility of Immediate Exclusion From Facility" That the department determine that S1 engaged in conduct inimical as a staff in the facility. BOD was informed to remove S1 from any contact with residents and S1 may not be physically present in any facility. BOD stated that S1's employment was terminated immediately after the incident. BOD agreed and understood.

The Department issued citation under 87468.1(a)(3) Personal Rights. S1 action towards R1 violated R1's personal rights when S1 pushed R1 away, causing R1 to fall and sustained abrasions on his/her right arm and a contusion and swelling to the back of his/her head.

An exit interview was conducted with Business Office Director Mary Ann Bangsal. Appeal rights was discussed and a copy of the report was provided.
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Maria Partoza
LICENSING EVALUATOR SIGNATURE: DATE: 10/18/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/18/2024
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 10/18/2024 11:40 AM - It Cannot Be Edited


Created By: Maria Partoza On 10/18/2024 at 09:11 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 SILVER CREEK
FACILITY NUMBER: 435202898

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/18/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Request Denied
Type A
10/18/2024
Section Cited
CCR
87468.1(a)(3)

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87468.1 Personal Rights of Residents in All Facilities (a)Residents in...residential care facilities for the elderly shall have … the following personal rights: (3) To be free from punishment,…abuse, or other actions of a punitive nature…This requirement is not met as evidenced by:
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Business Office Director stated that S1's employment was immediately terminated on 10/3/24 and reported the incident to CCLD, law enforcement, APS and LTCO. ADM stated that they provided staff training on elder abuse.
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Based on investigation S1 pushed R1 away causing R1 to fall. S1s action towards R1 violated R1s personal rights, which pose/poses an immediate health, safety and personal rights risks 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:Romeo Manzano
LICENSING EVALUATOR NAME:Maria Partoza
LICENSING EVALUATOR SIGNATURE:
DATE: 10/18/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/18/2024


LIC809 (FAS) - (06/04)
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