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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079201085
Report Date: 05/17/2022
Date Signed: 05/17/2022 03:19:52 PM

Document Has Been Signed on 05/17/2022 03:19 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, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME:OAKMONT OF CONCORDFACILITY NUMBER:
079201085
ADMINISTRATOR:STICKA, ANGELESFACILITY TYPE:
740
ADDRESS:1401 CIVIC COURTTELEPHONE:
(925) 798-4004
CITY:CONCORDSTATE: CAZIP CODE:
94520
CAPACITY: 121CENSUS: 85DATE:
05/17/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
12:30 PM
MET WITH:Julius Osorio,Operation SpecialistTIME COMPLETED:
04:00 PM
NARRATIVE
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On 5/17/2022, Licensing Program Analyst (LPA) L.Ibo conducted unannounced case management visit. LPA conducted in person Covid19 Initial positive intake. LPA met with Interim Executive Director Julius Osorio. LPA informed Julius O. the purpose of the visit.

Facility is under covid19 outbreak since 5/3/2022.

LPA observed the following:

· Residents not wearing mask

· Administrator failed to follow CCLD reporting requirements.

The deficiencies were observed (see LIC 809D) and cited from the California Code of Regulations. Failure to correct deficiencies by POC date may result in additional Civil Penalties.



Exit interview conducted. A copy of this report and appeal rights provided.

SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Leslie Ibo
LICENSING EVALUATOR SIGNATURE: DATE: 05/17/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/17/2022
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
Document Has Been Signed on 05/17/2022 03:19 PM - It Cannot Be Edited

Citations on this Visit Report are Under Appeal!


Created By: Leslie Ibo On 05/17/2022 at 01:45 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: OAKMONT OF CONCORD
FACILITY NUMBER: 079201085

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/17/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Under Appeal
Type B
05/27/2022
Section Cited
CCR
87211(a)(1)

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Reporting Requirements
(1) A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence ...
This requirement is not met by evidenced by:
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Administrator agrees to review regulation and conduct in-service training with staff on reporting requirements and submit a copy of training to CCL by POC date.
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Based on interview & records review, licensee did not comply with the regulation cited above which poses an potential health and safety risk for persons in care.
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Deficiency Dismissed
Type B
05/27/2022
Section Cited
CCR87211(a)(2)

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 Reporting Requirements (2) Occurrences, such as epidemic outbreaks... shall be reported within 24 hours either by telephone or facsimile to the licensing agency and to the local health officer when appropriate
This requirement is not met by evidenced by
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Administrator agrees to review regulation and conduct in-service training with staff on reporting requirements and submit a copy of training with signatures to CCL by POC date.
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Based on record review and observation licensee did not comply with the regulation cited above. Facility did not contact licensing within 24 hours of outbreak which poses an potential health and safety risk for persons 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:Harpreet Humpal
LICENSING EVALUATOR NAME:Leslie Ibo
LICENSING EVALUATOR SIGNATURE:
DATE: 05/17/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/17/2022


LIC809 (FAS) - (06/04)
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