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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496803601
Report Date: 08/06/2021
Date Signed: 08/06/2021 09:39:51 AM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928
FACILITY NAME:OAKMONT GARDENSFACILITY NUMBER:
496803601
ADMINISTRATOR:DEL DOSSO, MELISSAFACILITY TYPE:
740
ADDRESS:301 WHITE OAK DRTELEPHONE:
(707) 538-1914
CITY:SANTA ROSASTATE: CAZIP CODE:
95409
CAPACITY:79CENSUS: 37DATE:
08/06/2021
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Executive Director, John BeltzTIME COMPLETED:
10:00 AM
NARRATIVE
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During the course of a complaint investigation initiated on July 2, 2021, Licensing Program Analysts (LPA) Erik Gonzalez Campos and Farhaan Sarangi observed a deficiency that is not part of the original complaint.

On July 2, 2021 the regional office received an SOC341 and complaint regarding an incident that occurred June 28, 2021 when staff handled and spoke to a resident in care in an aggressive manner. Disciplinary action was taken with termination of the staff, however, the facility failed to submit an incident report to CCL within seven (7) days as required in Regulation 87211(a)(1)(D).

Deficiencies cited form the California Code of Regulations, Title 22, Division 6. Appeal rights given. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties.

SUPERVISOR'S NAME: Kimberley MotaTELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Erik Gonzalez CamposTELEPHONE: (707) 588-5026
LICENSING EVALUATOR SIGNATURE:

DATE: 08/06/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/06/2021
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928

FACILITY NAME: OAKMONT GARDENS
FACILITY NUMBER: 496803601
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/06/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
08/06/2021
Section Cited

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(D)–Reporting Requirements- A written report shall be submitted to the licensing agency …within 7 days of... any of the events specified in (A) - (D). (D) Any incident which threatens the welfare, safety or health of any resident … This requirement was not met as evidenced by:
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Based on record review and interviews facility failed to meet reporting requirements when an incident on 6/28/21 was not reported posing a potential health and safety risk to residents 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: Kimberley MotaTELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Erik Gonzalez CamposTELEPHONE: (707) 588-5026
LICENSING EVALUATOR SIGNATURE:
DATE: 08/06/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/06/2021
LIC809 (FAS) - (06/04)
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