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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 392701057
Report Date: 04/04/2024
Date Signed: 04/04/2024 12:14:10 PM

Document Has Been Signed on 04/04/2024 12:14 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 SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME:OAKMONT OF BROOKSIDEFACILITY NUMBER:
392701057
ADMINISTRATOR/
DIRECTOR:		TRACY BURKEFACILITY TYPE:
740
ADDRESS:3318 BROOKSIDE ROADTELEPHONE:
(209) 473-1300
CITY:STOCKTONSTATE: CAZIP CODE:
95219
CAPACITY: 81CENSUS: 72DATE:
04/04/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:54 AM
MET WITH:T. BurkeTIME VISIT/
INSPECTION COMPLETED:
12:30 PM
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On 4/4/2024, Licensing Program Analyst (LPA) Albert Johnson conducted an unannounced Case Management visit today at the facility. The department received two incident reports dated 3/28/2024 for a medication error for (R1) and 4/2/2024 for an unwitnessed fall for (R2).

LPA toured the facility and interviewed the Administrator about the events related to the medication error and the resident's fall.

The LPA reviewed resident records, staff records and staff training records. Medications and medication procedures were also reviewed. Both incident have been investigated by the department. The department confirmed that the facility has addressed these issues with an in-service training for Med-techs and has been actively working on the service plan for R2 since 9/29/2023. R2 was taken by the family to urgent care for a rash on 3/24/2024. R2 was diagnosed with Shingles and given two medications on that date. Both incidents were self reported by the facility.

Per California Code of Regulations, Title 22 Division 6, Chapter 8, no deficiencies were cited during this visit. Advisories were given.


Exit interview held and appeal rights given.
SUPERVISORS NAME: Lisa Rios
LICENSING EVALUATOR NAME: Albert Johnson
LICENSING EVALUATOR SIGNATURE: DATE: 04/04/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/04/2024
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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