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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 092700840
Report Date: 07/29/2021
Date Signed: 07/29/2021 02:12:46 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 520 COHASSET RD., STE. 170
CHICO, CA 95926
This is an official report of an unannounced visit/investigation of a complaint received in our office on
11/03/2020 and conducted by Evaluator Michael Smith
COMPLAINT CONTROL NUMBER: 27-AS-20201103143012
FACILITY NAME:VILLAGE OAKS SENIOR CARE, LLCFACILITY NUMBER:
092700840
ADMINISTRATOR:FOULK, BENJAMIN L.FACILITY TYPE:
740
ADDRESS:1011 ST. ANDREWS DRIVETELEPHONE:
(916) 293-1981
CITY:EL DORADO HILLSSTATE: CAZIP CODE:
95762
CAPACITY:15CENSUS: 10DATE:
07/29/2021
UNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Tanya GarciaTIME COMPLETED:
02:30 PM
ALLEGATION(S):
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Food services are inadequate.
INVESTIGATION FINDINGS:
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Prior to entering the facility, LPA Smith spoke with staff to pre-screen that the facility is COVID free. Analyst also self-screened for having no known symptoms or exposure. Analyst followed facility's screening protocols, wore an N-95 respirator and maintained distance during the visit. LPA Smith conducted an unannounced complaint visit and met with Tanya Garcia.

Visual inspection of 12 different food items, both perishable and non-perishable, were observed. None were expired. However, based on witness interviews, it was ascertained that residents were denied snacks upon request. This occurred usually, late at night or very early in the morning. According to the witnesses, this has not been a problem in the past several months, since the particular staff person, who denied snacks, no longer works at the facility. Based on this, this allegation is SUBSTANTIATED.

As a result of this investigation, LPA finds the allegation that food services are inadequate to be SUBSTANTIATED. A finding that the complaint is Substantiated means that the allegation is valid because the preponderance of the evidence standard has been met. The following deficiencies were cited on 9099-D, per Title 22 Regulations, Division 6.





Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Laura Munoz
LICENSING EVALUATOR NAME: Michael Smith
LICENSING EVALUATOR SIGNATURE:

DATE: 07/29/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/29/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 2
Control Number 27-AS-20201103143012
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 520 COHASSET RD., STE. 170
CHICO, CA 95926

FACILITY NAME: VILLAGE OAKS SENIOR CARE, LLC
FACILITY NUMBER: 092700840
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/29/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
07/26/2021
Section Cited
CCR
87555(b)(3)
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87555-General Food Service Requirements- Between meal nourishment or snacks shall be made available for all residents unless limited by dietary restrictions prescribed by a physician. This requirement is not met as evidenced by: Based on witness interviews, licensee did not allow snacks to residents upon
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Facility shall allow resident's to have snacks upon request. The staff member who violated this section, no longer works at the facility.

***Deficiency cleared during visit.
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request. This is in violation of this section. This poses a potential health and safety 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.
SUPERVISORS NAME: Laura Munoz
LICENSING EVALUATOR NAME: Michael Smith
LICENSING EVALUATOR SIGNATURE:

DATE: 07/26/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/26/2021
LIC9099 (FAS) - (06/04)
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