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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202898
Report Date: 10/08/2024
Date Signed: 10/08/2024 03:52:08 PM

Document Has Been Signed on 10/08/2024 03:52 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 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: 82DATE:
10/08/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:00 AM
MET WITH:Administrator Holly SuiterTIME VISIT/
INSPECTION COMPLETED:
03:55 PM
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Licensing Program Analyst (LPA) Manuel Monter conducted an unannounced follow up case management visit in regards an incident report, which stated a resident was allegedly pushed by a staff member. LPA's met with Administrator Holly Suiter. LPA's explained the purpose of the visit.

On October 4, 2024, the Department received an incident report, regarding resident R1. The incident report stated on October 3, 2024, at approximately 9:30pm, staff responded to a residents behavior in a physical manner. Resident sustained skin tear to elbows, and discoloration to back of head. Staff who responded in physical manner was terminated.

On October 8, 2024, LPA's interviewed staff S2 and resident R1.

(The Case management dated October 7, 2024, is being amended due to erroneous error made in the LIC809.)

LPA determined that the above incident requires further investigation. No deficiencies were cited at this time.

This report was reviewed with Administrator Holly Suiter and a copy of the report was provided.
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Manuel Monter
LICENSING EVALUATOR SIGNATURE: DATE: 10/08/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/08/2024
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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