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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079201083
Report Date: 05/05/2023
Date Signed: 05/05/2023 02:56:08 PM


Document Has Been Signed on 05/05/2023 02:56 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
E BAY DELTA AC/SC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612



FACILITY NAME:MONTECITO OAKMONT SENIOR LIVINGFACILITY NUMBER:
079201083
ADMINISTRATOR:WONG, ELAINEFACILITY TYPE:
740
ADDRESS:4756 CLAYTON ROADTELEPHONE:
(925) 692-5838
CITY:CONCORDSTATE: CAZIP CODE:
94521
CAPACITY:230CENSUS: 230DATE:
05/05/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:45 AM
MET WITH:Elaine Wong, Executive DirectorTIME COMPLETED:
03:15 PM
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On 5/5/2023 at 9:45 AM, Licensing Program Analyst (LPA) P. Watson arrived unannounced to conduct Required 1 Year Annual inspection. LPA met with Executive Director, Elaine Wong and explained the purpose of the visit. The facility’s fire clearance was approved for 224 Non-Ambulatory and 6 Bedridden.

LPA toured the facility with Elaine including but not limited to 5 residents’ apartments, bathrooms, activity rooms, kitchen, common area and courtyard. LPA observed a locked gate surrounding the pool area. LPA observed lighting in all rooms are adequate for the comfort and safety of the residents. Hallway temperature was maintained at 76 degrees Fahrenheit. The hot water temperature in a sample of residents’ bathrooms were measured at 115.3, 112.5, 109.9 degrees Fahrenheit. Residents’ bathrooms are equipped with grab bars and non-skid mats. There is a minimum of 7 day supply of nonperishable and 2 day of perishable foods. Centrally stored medications, sharps and toxic are locked and inaccessible to residents in care.

Smoke detectors and carbon monoxide detector were in operating condition. Fire extinguishers were last serviced on 9/14/2022 . Emergency disaster drill was last conducted on 3/23/2023 . First aid kit was observed to be complete.



Report continues on 809-C
SUPERVISOR'S NAME: Yvonne Flores-LariosTELEPHONE: (510) 725-7926
LICENSING EVALUATOR NAME: Paris WatsonTELEPHONE: (510) 622-2625
LICENSING EVALUATOR SIGNATURE:
DATE: 05/05/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/05/2023
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
E BAY DELTA AC/SC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME: MONTECITO OAKMONT SENIOR LIVING
FACILITY NUMBER: 079201083
VISIT DATE: 05/05/2023
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At 11:26 AM, LPA reviewed 10 of 230 residents records. At 12:15 PM, LPA reviewed 10 of 120 staff records and 10 of 10 have current first aid training and associated to the facility. At 1:45 PM, LPA reviewed a sample of 10 of 230 resident’s medications.


Updated copies of the following documents were requested for facility file and are to be submitted to CCL by 5/26/2023:

LIC 308 Designation of Administrative Responsibility
LIC 309 Administrative Organization
LIC 500 Personnel Report
LIC 610E Emergency Disaster Plan
Liability Insurance
Current Administrator’s Certificate
SUPERVISOR'S NAME: Yvonne Flores-LariosTELEPHONE: (510) 725-7926
LICENSING EVALUATOR NAME: Paris WatsonTELEPHONE: (510) 622-2625
LICENSING EVALUATOR SIGNATURE:

DATE: 05/05/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/05/2023
LIC809 (FAS) - (06/04)
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