079201085-8-1-2023-15-AS-PWAN-CUATVS-20230801150426

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 079201085
Report Date: 08/01/2023
Date Signed: 08/01/2023 03:04:37 PM

Document Has Been Signed on 08/01/2023 03:04 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:	OAKMONT OF CONCORD		FACILITY NUMBER:	079201085
ADMINISTRATOR:	NGUYEN, AVON		FACILITY TYPE:	740
ADDRESS:	1401 CIVIC COURT		TELEPHONE:	(925) 798-4004
CITY:	CONCORD	STATE: CA	ZIP CODE:	94520
CAPACITY:	121	CENSUS: 88	DATE:	08/01/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	10:30 AM
MET WITH:	Rachel Benoza, Resident Care Coordinator San Sor, Executive Director		TIME COMPLETED:	03:15 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	On 08/01/2023 at 10:30 AM, Licensing Program Analyst (LPA) P. Watson arrived unannounced to conduct Required 1 Year Annual inspection. LPA met with Resident Care Coordinator, Rachel Benoza and Executive Director, San Sor and explained the purpose of the visit. The facility’s fire clearance was approved for 113 Non Ambulatory and 8 Bedridden. LPA toured the facility with San Sor including but not limited to 3 residents’ apartments, activity rooms, kitchen, common areas and courtyard. LPA observe lighting in all rooms are adequate for the comfort and safety of the residents. Hallway temperature was maintained at 73 degrees F. The hot water temperature in a sample of residents' bathrooms were measured at 114.3, 113.7 & 114.8 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 and sharps are locked and inaccessible to residents. Smoke and carbon monoxide detectors are interconnected with sprinkler system. Fire extinguishers were last serviced on 02/06/2023. First aid kit was complete. Report continues on 809 C.

SUPERVISOR'S NAME: Yvonne Flores-Larios	TELEPHONE: (510) 725-7926
LICENSING EVALUATOR NAME: Paris Watson	TELEPHONE: (510) 622-2625
LICENSING EVALUATOR SIGNATURE:	DATE: 08/01/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/01/2023

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)

Page: 1 of 2

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: OAKMONT OF CONCORD	FACILITY NUMBER: 079201085
	VISIT DATE: 08/01/2023

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

At 11:00 AM, LPA reviewed 8 of 88 residents records. At 12:30 PM, LPA reviewed 10 of 103 staff records and 10 of 10 have current first aid training and associated to the facility. At 2:10 PM, LPA reviewed a sample of 8 of 88 resident’s medications.

Updated copies of the following documents were requested for facility file and are to be submitted to CCL by 08/22/2023:

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

No deficiencies cited during visit. Exit interview conducted and a copy of this report provided.

SUPERVISOR'S NAME: Yvonne Flores-Larios	TELEPHONE: (510) 725-7926
LICENSING EVALUATOR NAME: Paris Watson	TELEPHONE: (510) 622-2625
LICENSING EVALUATOR SIGNATURE:	DATE: 08/01/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/01/2023

LIC809 (FAS) - (06/04)

Page: 2 of 2