315002798-8-29-2025-59-AS-CYAG-DKZUS5-20250829154945

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 315002798
Report Date: 08/29/2025
Date Signed: 08/29/2025 03:49:55 PM

Document Has Been Signed on 08/29/2025 03:49 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
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME:	OAKMONT OF ROSEVILLE		FACILITY NUMBER:	315002798
ADMINISTRATOR/ DIRECTOR:	ANGELIQUE DOYLE		FACILITY TYPE:	740
ADDRESS:	1101 SECRET RAVINE PARKWAY		TELEPHONE:	(916) 771-6700
CITY:	ROSEVILLE	STATE: CA	ZIP CODE:	95661
CAPACITY: 120		CENSUS: 76	DATE:	08/29/2025
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	12:45 PM
MET WITH:	Angelique Doyle		TIME VISIT/ INSPECTION COMPLETED:	04:00 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 August 29, 2025, Licensing Program Analyst (LPA) Cassie Yang arrived unannounced at the facility to conduct a required annual inspection. LPA met with Executive Director (ED), and explained the purpose of the visit. Today's census is 76 residents in care, with four residents on hospice. Facility is licensed for 120 residents, hospice waiver of 15. Today's inspection, LPA and ED conducted a tour of the interior and exterior of the facility to ensure the health and safety of residents in care. Areas toured included but not limited to: facility courtyards, library, private dining room, main dining rooms, activity room, fitness center, media room, laundry room, business office and residents bedrooms and bathrooms. LPA observed fire extinguisher present throughout the facility with recent service date of August 13, 2025. LPA observed residents in care, participating in yoga session. LPA observed residents playing bingo in the activity room. LPA observed residents to be doing physical therapy in the fitness center. In areas toured, LPA observed no health, safety and personal rights violations. LPA conducted a file review of eight resident records and eight personnel records. LPA observed resident records to have the required documents completed. LPA observed personnel records to have required initial training. When asked, Business Director informed LPA that not all care providers are provided cardiopulmonary resuscitation (CPR) training. Business Director stated all culinary staff, working 6 AM to 8 PM, are CPR certified. Additionally, the care providers and medication technicians on nocturnal (NOC) shift are CPR certified to ensure that at least one staff member who has CPR training and first aid training is on duty and on the premises at all times. Continue LIC 809-C

NAME OF LICENSING PROGRAM MANAGER: Anthony Perez
NAME OF LICENSING PROGRAM ANALYST: Cassie Yang
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 08/29/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/29/2025

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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California Health & Human Services Agency

California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:

Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.

Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)

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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
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: OAKMONT OF ROSEVILLE	FACILITY NUMBER: 315002798
	VISIT DATE: 08/29/2025

NARRATIVE

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LIC 809-C

LPA completed the CARE tool and found facility to be compliance.

At this time, LPA is requesting a copy of liability insurance and LIC 308 to be emailed to LPA by September 5, 2025.

As a result of today's visit, no deficiencies cited.

At time of exit interview, ED was unavailable. Report was signed with Business Director.

Exit interview conducted and a copy of report was provided.

NAME OF LICENSING PROGRAM MANAGER: Anthony Perez
NAME OF LICENSING PROGRAM ANALYST: Cassie Yang
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 08/29/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/29/2025

LIC809 (FAS) - (06/04)

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