097001962-9-8-2022-25-AS-KHOS-CK4MG4-20221011093520

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 097001962
Report Date: 09/08/2022
Date Signed: 09/08/2022 11:16:40 AM

Unfounded

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CHICO - RESIDENTIAL, 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
07/22/2022 and conducted by Evaluator Kerry Hiratsuka

COMPLAINT CONTROL NUMBER: 25-AS-20220722104110

FACILITY NAME:	OAK GROVE SENIOR CARE		FACILITY NUMBER:	097001962
ADMINISTRATOR:	OMITA KAHN		FACILITY TYPE:	740
ADDRESS:	2920 TAM O'SHANTER DRIVE		TELEPHONE:	(916) 939-0962
CITY:	EL DORADO HILLS	STATE: CA	ZIP CODE:	95762
CAPACITY:	6	CENSUS: 5	DATE:	09/08/2022
		UNANNOUNCED	TIME BEGAN:	08:30 AM
MET WITH:	Omita Khan		TIME COMPLETED:	11:25 AM

ALLEGATION(S):

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Staff did not provide a bed for resident

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Kerry Hiratsuka arrived at the facility unannounced to conduct a Complaint Investigation Visit. LPA conducted COVID-19 Precautionary prescreening, and wore a surgical mask while at facility. LPA was screened by Caregiver.

LPA investigated the allegation “Staff did not provide a bed for resident.” LPA interviewed staff and the interviews stated all residents have beds. The allegation also included that one resident was moved to this facility from the facility next door because the other facility owned by the same licensee didn't hav any supervision. LPA unfounded that allegation as well.

Unfounded

Estimated Days of Completion:

SUPERVISOR'S NAME: Troy Ordonez	TELEPHONE: (916) 263-4832
LICENSING EVALUATOR NAME: Kerry Hiratsuka	TELEPHONE: (916) 591-0210
LICENSING EVALUATOR SIGNATURE:	DATE: 09/08/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/08/2022

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 25-AS-20220722104110

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CHICO - RESIDENTIAL, 520 COHASSET RD., STE. 170
CHICO, CA 95926

FACILITY NAME: OAK GROVE SENIOR CARE	FACILITY NUMBER: 097001962
	VISIT DATE: 09/08/2022

NARRATIVE

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“This agency has investigated the complaint alleging; Staff did not provide a bed for resident. We have found that the complaint was unfounded, meaning that the allegation was false, could not have happened and/or is without a reasonable basis."

LPA Hiratsuka, was given permission by Administrator to type up this report at Oak Hill Senior Care 97001794 because they are owned by the same licensee. LPA interviewed staff and residents at this facility.

SUPERVISOR'S NAME: Troy Ordonez	TELEPHONE: (916) 263-4832
LICENSING EVALUATOR NAME: Kerry Hiratsuka	TELEPHONE: (916) 591-0210
LICENSING EVALUATOR SIGNATURE:	DATE: 09/08/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/08/2022

LIC9099 (FAS) - (06/04)

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