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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 097005553
Report Date: 03/27/2023
Date Signed: 03/27/2023 04:46:30 PM

Document Has Been Signed on 03/27/2023 04:46 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, 2525 NATOMAS PARK DR STE 270
SACRAMENTO, CA 95833
FACILITY NAME:OAK CREEK SENIOR CAREFACILITY NUMBER:
097005553
ADMINISTRATOR:DR. BENJAMIN FOULKFACILITY TYPE:
740
ADDRESS:2908 TAM O'SHANTER DRIVETELEPHONE:
(916) 939-0962
CITY:EL DORADO HILLSSTATE: CAZIP CODE:
95762
CAPACITY: 6CENSUS: 5DATE:
03/27/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:20 PM
MET WITH:Adelina PimentelTIME COMPLETED:
05:00 PM
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Licensing Program Analysts (LPAs) Melissa Parks and Lavinia Muscan arrived on Monday March 27, 2023 to conduct the annual inspection.

During today's annual inspection, LPAs reviewed 2 staff files, 5 client files, and fire drill records.

LPA Parks and Administrator Rod Fleeman toured the facility together to ensure the health and safety of residents in care. The areas toured included resident rooms, bathrooms, kitchen, and the pantry.

This inspection will be concluded on a further date. The CAREs tool will be used on the following inspection.

LPAs obtained copies of S1 and S2's training and food menu.

No deficiencies cited. Exit interview conducted. A copy of this report was emailed to RCC Surge Entona..
SUPERVISORS NAME: Maribeth Senty
LICENSING EVALUATOR NAME: Melissa Parks
LICENSING EVALUATOR SIGNATURE: DATE: 03/27/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/27/2023
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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