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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 097001962
Report Date: 09/05/2023
Date Signed: 09/05/2023 03:14:51 PM


Document Has Been Signed on 09/05/2023 03:14 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 NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827



FACILITY NAME:OAK GROVE SENIOR CAREFACILITY NUMBER:
097001962
ADMINISTRATOR:OMITA KAHNFACILITY TYPE:
740
ADDRESS:2920 TAM O'SHANTER DRIVETELEPHONE:
(916) 939-0962
CITY:EL DORADO HILLSSTATE: CAZIP CODE:
95762
CAPACITY:6CENSUS: 5DATE:
09/05/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
01:46 PM
MET WITH:Administrator Jennifer Hinch TIME COMPLETED:
03:15 PM
NARRATIVE
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Licensing Program Manager (LPM) Laura Munoz and Licensing Program Analyst (LPA) Lavinia Muscan arrived at the facility unannounced on 9/5/2023 and met with Licensee, Ben Foulk and Administrator Jennifer Hinch and explained the purpose of the visit.

The Department conducted a joint visit today with El Dorado Hills Fire District. On 02/21/2023, the fire district issued the facility a correction notice with items that needed to be corrected for the facility to meet fire code requirements. As of this date, the noted deficiencies have not been corrected. The fire district will be issuing a second correction notice today with a due date of 7 calendar days from today’s date. A follow up visit will be conducted to ensure that corrections have been made.

Today's visit is to check the health and safety of residents in care. Based on records reviewed it has been determined that Licensee has an overdue license fee. This facility has an outstanding balance for fees due. The current amount owed is $2,968.00 and was billed on 1/4/2023. As of this date, the fees are overdue. LPA explained to Administrator that proof of payment and/or proof of payment plan needs to be provided to CCL by the date given. Additionally, based on observation, facility appears to have a leak in the living room that is in need of repair and a bed located in a room that is designated as an office. This poses an potential risk to residents in care.

Per California Code of Regulations, Title 22 Division 6, Chapter 8, B deficiencies are being cited today in violation of California Code of Regulations and follows on 809-D.

Exit interview conducted and appeal rights provided.
SUPERVISOR'S NAME: Laura MunozTELEPHONE: (916) 263-4743
LICENSING EVALUATOR NAME: Lavinia MuscanTELEPHONE: 916-263-4700
LICENSING EVALUATOR SIGNATURE:
DATE: 09/05/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/05/2023
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


Document Has Been Signed on 09/05/2023 03:14 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827


FACILITY NAME: OAK GROVE SENIOR CARE
FACILITY NUMBER: 097001962

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/05/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/05/2023
Section Cited
CCR
87303(a)

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Maintenance and Operation (a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors.
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By 10/05/2023 Licensee agrees to submit proof of correction and understanding of the regulation to the department.
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This requirement has not been met as evidenced by: Based on department’s facility walkthrough, facility appeared to have a leak in the living room that is in need of repair and a bed located in an office that is not designated as a bedroom. This poses an potential risk to residents in care.
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Type B
10/05/2023
Section Cited
HSC1569.185(a)(1)

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1569.185 Fees for license or applications; use of revenues; collected; denial or forfeiture (a)(1) An application fee adjusted by facility and capacity shall be charged by the department for the issuance of a license to operate a residential care facility for the elderly. After initial licensure, a fee shall be charged by the department annually on each anniversary of the effective date of the license …
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By 10/5/23, the licensee shall contact Community Care Licensing to pay the entire fee due. Failure to correct shall result in civil penalties.
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This requirement has not been met as evidenced by: Based on department's review of annual fees not being paid. This does not pose an immediate risk to residents.
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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.
SUPERVISOR'S NAME: Laura MunozTELEPHONE: (916) 263-4743
LICENSING EVALUATOR NAME: Lavinia MuscanTELEPHONE: 916-263-4700
LICENSING EVALUATOR SIGNATURE:
DATE: 09/05/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/05/2023
LIC809 (FAS) - (06/04)
Page: 2 of 2