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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202898
Report Date: 10/15/2024
Date Signed: 10/15/2024 04:28:47 PM


COMPREHENSIVE INSPECTION

Document Has Been Signed on 10/15/2024 04:28 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
CENTRAL COAST CR/RES, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131
FACILITY NAME:OAKMONT OF SILVER CREEKFACILITY NUMBER:
435202898
ADMINISTRATOR/
DIRECTOR:		DIAL, JAMESFACILITY TYPE:
740
ADDRESS:3544 SAN FELIPE ROADTELEPHONE:
(669) 200-2443
CITY:SAN JOSESTATE: CAZIP CODE:
95135
CAPACITY: 148CENSUS: 79DATE:
10/15/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
02:00 PM
MET WITH:Mary Ann Bangal - Business Office DirectorTIME VISIT/
INSPECTION COMPLETED:
04:30 PM
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Licensing Program Analysts (LPAs) Maria (Mita) Partoza and Marcella Tarin conducted an unannounced required 1 year inspection visit and met with Business office Director (BOD) Mary Ann Bangsal. Administrator(ADM) Holly Suiter was not present due to required training. LPAs stated the purpose of the visit.

The facility is licensed to serve adults 60 and over, 140 ambulatory, 8 non-ambulatory and hospice waiver for 15.

At 2:18 p.m. LPA Tarin toured the facility inside and outside with maintenance director (MD) including but not limited to the kitchen, assisted living area, memory care, reception and exterior perimeters and walkways. The temperature inside the facility is at 75 degrees Fahrenheit.

The kitchen was observed to be sanitary and organized, knives and sharps were locked and not accessible to residents. LPA observed 2 days of perishable food and 7 days of non-perishable food. The kitchen water temperature measured at 107.9 to 112. 4 degrees Fahrenheit.

The bathroom/s are equipped with grab bars, non-skid floors. The water temperature in the bathroom measured at 112.4 degrees Fahrenheit and rooms have sufficient storage.

The facility is equipped with a fire, smoke and carbon monoxide alert system that is in good working condition, night lights on the hallway are in good working condition. The hallway are free from obstruction. Fire extinguishers were last serviced 12/15/2023.

page 1 of 2, see LIC 809C
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Maria Partoza
LICENSING EVALUATOR SIGNATURE: DATE: 10/15/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/15/2024
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
CENTRAL COAST CR/RES, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131
FACILITY NAME: OAKMONT OF SILVER CREEK
FACILITY NUMBER: 435202898
VISIT DATE: 10/15/2024
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LPA reviewed 5 resident records such as but not limited to the centrally stored medication and destruction record (CSMDR), admission agreement, needs and services plan, health screening and observed records to be complete and updated.

LPA reviewed 5 staff records including but not limited to required training, first aid/CPR training, health screening and background clearance. All staff have criminal record clearance/fingerprints. 3 out of 5 were care providers. 1 Out of 5 is a server and 1 out of 5 is a housekeeper.

No deficiencies were cited during today's visit based on California Code of Regulation (CCR) Title 22. An exit interview was conducted with Business Office Director (BOD) Mary Ann Bangsal and a copy of the report was provided.

page 2 of 2 end of report
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Maria Partoza
LICENSING EVALUATOR SIGNATURE:

DATE: 10/15/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/15/2024
LIC809 (FAS) - (06/04)
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