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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079200771
Report Date: 02/08/2023
Date Signed: 02/08/2023 11:25:21 AM


Document Has Been Signed on 02/08/2023 11:25 AM - 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:OAKLEY ASSISTED LIVING LLCFACILITY NUMBER:
079200771
ADMINISTRATOR:LAKE, NICOLETTEFACILITY TYPE:
740
ADDRESS:531 O'HARA AVETELEPHONE:
(925) 219-6165
CITY:OAKLEYSTATE: CAZIP CODE:
94561
CAPACITY:6CENSUS: 5DATE:
02/08/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
10:15 AM
MET WITH:LAKE, NICOLETTE, Administrator TIME COMPLETED:
11:40 AM
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On 02/08/2023, Licensing Program Analysts (LPAs) L. Ibo and L. Alexander conducted an unannounced case management visit in regard to the unusual incident report received on 2/3/2023. LPAs met with Administrator, Nicolette Lake and explained the purpose of the visit.

Based on unusual report received, on 2/2/2023, R1 was being fed his breakfast and was holding his mouth then he made chocking sound, his face begun to pale, and his lips was bluish he then coughed and started breathing again. Staff called 9-1-1. R1 was brought to nearby hospital. Around 2:15PM R1 was pronounced dead at the hospital. Records review and interview revealed that R1 was not under hospice care.

LPAs gathered documents such as but not limited to; LIC602, pre-appraisal needs and care plan. LPAs requested from Administrator a copy of death certificate and copy of Physician orders for life-sustaining treatment (POLST).

LPAs do not have available documents currently. LPAs will return to the facility as soon as all information are received.

Exit interview conducted with Nicolette Lake. A copy of this report provided.
SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Leslie IboTELEPHONE: 510-286-4201
LICENSING EVALUATOR SIGNATURE:
DATE: 02/08/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/08/2023
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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