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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 345002797
Report Date: 05/21/2024
Date Signed: 05/21/2024 04:56:06 PM

Document Has Been Signed on 05/21/2024 04:56 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
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME:OAKMONT OF FAIR OAKSFACILITY NUMBER:
345002797
ADMINISTRATOR/
DIRECTOR:		POUYA ANSARIFACILITY TYPE:
740
ADDRESS:8484 MADISON AVE.TELEPHONE:
(916) 633-1001
CITY:FAIR OAKSSTATE: CAZIP CODE:
95628
CAPACITY: 128CENSUS: 84DATE:
05/21/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
04:30 PM
MET WITH:Pouya Ansari, Executive DirectorTIME VISIT/
INSPECTION COMPLETED:
05:00 PM
NARRATIVE
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Licensing Program Analyst (LPA) Michael Hood arrived at the facility and met with Executive Director (ED), Pouya Ansari, to follow-up regarding information obtained after previous inspection.

Based on records reviewed by the Department, ED does not currently have an active Administrator certificate. A deficiencies is being cited pursuant to California Code of Regulations, Title 22, Division 6, Chapter 8. Deficiency is listed on the attached 809-D page.

Exit interview was conducted with ED. A copy of this report and appeal rights were provided. ED's signature on these forms acknowledges receipt of these documents.
SUPERVISORS NAME: Anthony Perez
LICENSING EVALUATOR NAME: Michael Hood
LICENSING EVALUATOR SIGNATURE: DATE: 05/21/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/21/2024
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 05/21/2024 04:56 PM - It Cannot Be Edited


Created By: Michael Hood On 05/21/2024 at 04:29 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
, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: OAKMONT OF FAIR OAKS
FACILITY NUMBER: 345002797

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/21/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
06/03/2024
Section Cited
CCR
87405(a)

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87405 Administrator - Qualifications and Duties (a) All facilities shall have a qualified and currently certified administrator. (...) This requirement is not met as evidenced by:
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Facility will submit required paperwork to assign an individual with an active Administrator certificate as the facility's Administrator by POC due date of 6/03/2024.
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Based on records reviewed, the facility did not ensure that Administrator had an active Administrator certificate, which poses an potential health, safety, and personal rights risk to 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:Anthony Perez
LICENSING EVALUATOR NAME:Michael Hood
LICENSING EVALUATOR SIGNATURE:
DATE: 05/21/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/21/2024


LIC809 (FAS) - (06/04)
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