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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496803998
Report Date: 07/31/2023
Date Signed: 07/31/2023 02:41:19 PM


Document Has Been Signed on 07/31/2023 02:41 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, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405



FACILITY NAME:OAKMONT GARDENSFACILITY NUMBER:
496803998
ADMINISTRATOR:SORIANO, MARIELEFACILITY TYPE:
740
ADDRESS:301 WHITE OAK DRIVETELEPHONE:
(707) 921-1861
CITY:SANTA ROSASTATE: CAZIP CODE:
95409
CAPACITY:79CENSUS: 46DATE:
07/31/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Administrator, Morgan HolienTIME COMPLETED:
03:00 PM
NARRATIVE
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Licensing Program Analyst (LPA), Farhaan Sarangi arrived unannounced at Oakmont Gardens for the purpose of conducting a Case Management-Deficiency Inspection. LPA was greeted by Administrator, Morgan Holien, and was granted access into the facility.

During the course of the complaint investigation, LPA reviewed documents and determined that Resident #1 was missing the most recent LIC 602/Physician Assessment. During the delivery of complaint findings on July 31, 2023, LPA requested to review the most recent LIC 602 for Resident #1. The Administrator disclosed to the LPA that the LIC 602 was unavailable for viewing due to the facility not retaining the updated LIC 602 (See LIC 809D). LPA educated the Administrator about the importance of retaining Resident Records as outlined in Title 22 regulations.

The following deficiencies were observed (See LIC 809D) and cited from the California Code of Regulations, Title 22, Division 6 of California Regulation. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in additional civil penalties. Exit interview conducted with the Administrator and appeal rights were provided.
SUPERVISOR'S NAME: Hope DeBenedettiTELEPHONE: (707) 588-5029
LICENSING EVALUATOR NAME: Farhaan SarangiTELEPHONE: 707-588-5034
LICENSING EVALUATOR SIGNATURE:
DATE: 07/31/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/31/2023
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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Document Has Been Signed on 07/31/2023 02:41 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405


FACILITY NAME: OAKMONT GARDENS
FACILITY NUMBER: 496803998

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/31/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
08/07/2023
Section Cited
CCR
87506(a)(10)

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87506(a)(10) Resident Records:

(a) The licensee shall ensure that a separate, complete, and current record is maintained for each resident in the facility or in a central administrative location readily available to facility staff and to licensing agency staff.

(10) Reports of the medical assessment specified in Section 87458, Medical Assessment, and of any special problems or precautions.
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Plan of Correction shall include Licensee submitting a LIC 9098-Self Certification form and providing a statement on future compliance. In addition, Licensee shall train staff on record keeping.
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This requirement was not met as evidenced by:

During the course of the complaint investigation, LPA reviewed documents and determined that Resident #1 was missing the most recent LIC 602/Physician Assessment. During the delivery of complaint findings on July 31, 2023, LPA requested to review the most recent LIC 602 for Resident #1. The Administrator disclosed to the LPA that the LIC 602 was unavailable for viewing due to the facility not retaining the updated LIC 602. This is a potential Health, Safety and Personal Rights risk to the 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: Hope DeBenedettiTELEPHONE: (707) 588-5029
LICENSING EVALUATOR NAME: Farhaan SarangiTELEPHONE: 707-588-5034
LICENSING EVALUATOR SIGNATURE:
DATE: 07/31/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/31/2023
LIC809 (FAS) - (06/04)
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