<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES
Community Care Licensing
FACILITY EVALUATION REPORT
Facility Number:
312700265
Report Date:
08/16/2023
Date Signed:
08/16/2023 04:27:42 PM
Document Has Been Signed on
08/16/2023 04:27 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:
OASIS FOR SENIORS AT HEAVEN'S GARDEN
FACILITY NUMBER:
312700265
ADMINISTRATOR:
TODEREAN, ADELA
FACILITY TYPE:
740
ADDRESS:
6203 TWO TOWERS COURT
TELEPHONE:
(916) 781-9179
CITY:
ROCKLIN
STATE:
CA
ZIP CODE:
95765
CAPACITY:
6
CENSUS:
6
DATE:
08/16/2023
TYPE OF VISIT:
Required - 1 Year
UNANNOUNCED
TIME BEGAN:
02:25 PM
MET WITH:
Adela Toderean, Administrator
TIME COMPLETED:
04:45 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
Licensing Program Analyst (LPA) Bethany Mirlohi arrived unannounced to conduct an annual inspection. LPA met with administrator Adela Toderean during today's inspection. LPA ensured they applied hand sanitizer before entering the facility.
LPA toured facility with administrator to ensure health and safety of residents in care. LPA toured 5 resident rooms, 1 staff room, 2 bathrooms, kitchen, common living spaces, backyard and the garage area.
LPA toured the backyard area and observed emergency exit was locked. There is a locked storage for medications and toxins. Food supply is adequate for 2-day perishable and 7-day nonperishable. LPA observed an adequate amount of linens and found the first aid kit to be complete.
LPA reviewed 2 of 6 resident files and 2 staff files.
LPA reviewed medications of one resident comparing with Centrally Stored Medication Record and physician orders. A review of staff records indicates that all facility staff has received criminal record clearances and/or are associated to this facility.LPA observed a copy of current liability insurance.
There are deficiencies being cited as a result of todays inspection. Deficiencies cited on 809-D.
Exit interview conducted and appeal rights provided.
SUPERVISOR'S NAME:
Troy Ordonez
TELEPHONE:
(916) 263-4832
LICENSING EVALUATOR NAME:
Bethany Mirlohi
TELEPHONE:
(916) 204-8288
LICENSING EVALUATOR SIGNATURE:
DATE:
08/16/2023
I acknowledge receipt of this form and understand my
licensing
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
08/16/2023
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
5
Document Has Been Signed on
08/16/2023 04:27 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
,
2525 NATOMAS PARK DR STE 270
SACRAMENTO
,
CA
95833
FACILITY NAME:
OASIS FOR SENIORS AT HEAVEN'S GARDEN
FACILITY NUMBER:
312700265
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE:
08/16/2023
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87705(l)(2)
Care of Persons with Dementia
(l) The following initial and continuing requirements shall be met for the licensee to lock exterior doors or perimeter fence gates: (2) The licensee shall ensure that the fire clearance includes approval of locked exterior doors or locked perimeter fence gates.
This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, the licensee did not comply with the section cited above by locking gate to emergency exit which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date:
08/17/2023
Plan of Correction
1
2
3
4
Administrator agrees to remove the lock immediately. In addition, administrator agrees to submit a statement of understanding that all emergency exits must remain accessible.
Section Cited
Deficient Practice Statement
1
2
3
4
POC Due Date:
Plan of Correction
1
2
3
4
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:
Troy Ordonez
TELEPHONE:
(916) 263-4832
LICENSING EVALUATOR NAME:
Bethany Mirlohi
TELEPHONE:
(916) 204-8288
LICENSING EVALUATOR SIGNATURE:
DATE:
08/16/2023
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
08/16/2023
LIC809
(FAS) - (06/04)
Page:
2
of
5
Document Has Been Signed on
08/16/2023 04:27 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
,
2525 NATOMAS PARK DR STE 270
SACRAMENTO
,
CA
95833
FACILITY NAME:
OASIS FOR SENIORS AT HEAVEN'S GARDEN
FACILITY NUMBER:
312700265
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE:
08/16/2023
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87411(f)
Personnel Requirements - General
(f) All personnel, including the licensee and administrator, shall be in good health, and physically and mentally capable of performing assigned tasks. Good physical health shall be verified by a health screening, including a chest x-ray or an intradermal test, performed by a physician not more than six (6) months prior to or seven (7) days after employment or licensure. A report shall be made of each screening, signed by the examining physician. The report shall indicate whether the person is physically qualified to perform the duties to be assigned, and whether he/she has any health condition that would create a hazard to him/herself, other staff members or residents. A signed statement shall be obtained from each volunteer affirming that he/she is in good health. Personnel with evidence of physical illness or emotional instability that poses a significant threat to the well-being of residents shall be relieved of their duties.
This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review, the licensee did not comply with the section cited above in 1 out of 2 persons which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date:
08/30/2023
Plan of Correction
1
2
3
4
Administrator agrees to obtain a health care screening (LIC503) for caregiver 1 and a TB test. Copy of report to be sent into CCL by 8/30/23.
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:
Troy Ordonez
TELEPHONE:
(916) 263-4832
LICENSING EVALUATOR NAME:
Bethany Mirlohi
TELEPHONE:
(916) 204-8288
LICENSING EVALUATOR SIGNATURE:
DATE:
08/16/2023
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
08/16/2023
LIC809
(FAS) - (06/04)
Page:
3
of
5
Document Has Been Signed on
08/16/2023 04:27 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
,
2525 NATOMAS PARK DR STE 270
SACRAMENTO
,
CA
95833
FACILITY NAME:
OASIS FOR SENIORS AT HEAVEN'S GARDEN
FACILITY NUMBER:
312700265
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE:
08/16/2023
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.618(c)(3)
Other Provisions
(c) The facility shall employ, and the administrator shall schedule, a sufficient number of staff members to do all of the following: (3) Ensure that at least one staff member who has cardiopulmonary resuscitation (CPR) training and first aid training is on duty and on the premises at all times. This paragraph shall not be construed to require staff to provide CPR.
This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review, the licensee did not comply with the section cited above in 1 out of 1 persons which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date:
08/30/2023
Plan of Correction
1
2
3
4
Administrator agrees to obtain an updated CPR and first aide card for caregiver 2. Certificate to be sent into CCL by 8/30/23.
Type B
Section Cited
HSC
1569.625(b)(2)
Other Provisions
(2) In addition to paragraph (1), training requirements shall also include an additional 20 hours annually, eight hours of which shall be dementia care training, as required by subdivision (a) of Section 1569.626, and four hours of which shall be specific to postural supports, restricted health conditions, and hospice care, as required by subdivision (a) of Section 1569.696. This training shall be administered on the job, or in a classroom setting, or both, and may include online training.
This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review, the licensee did not comply with the section cited above in 1 out of 1 persons which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date:
08/30/2023
Plan of Correction
1
2
3
4
Administrator agrees to complete a training calendar for caregiver 2 to show when required training will be completed. Calendar to be submitted into CCL by 8/30/23.
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:
Troy Ordonez
TELEPHONE:
(916) 263-4832
LICENSING EVALUATOR NAME:
Bethany Mirlohi
TELEPHONE:
(916) 204-8288
LICENSING EVALUATOR SIGNATURE:
DATE:
08/16/2023
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
08/16/2023
LIC809
(FAS) - (06/04)
Page:
4
of
5
Document Has Been Signed on
08/16/2023 04:27 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
,
2525 NATOMAS PARK DR STE 270
SACRAMENTO
,
CA
95833
FACILITY NAME:
OASIS FOR SENIORS AT HEAVEN'S GARDEN
FACILITY NUMBER:
312700265
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE:
08/16/2023
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87467(a)(3)
Resident Participation in Decisionmaking
(a) Prior to, or within two weeks of the resident's admission, the licensee shall arrange a meeting with the resident, the resident's representative, if any, appropriate facility staff, and a representative of the resident's home health agency, if any, and any other appropriate parties, to prepare a written record of the care the resident will receive in the facility, and the resident's preferences regarding the services provided at the facility. (3) The licensee shall arrange a meeting with the resident and appropriate individuals identified in Section 87467(a)(1) to review and revise the written record as specified, when there is a significant change in the resident's condition, or once every 12 months, whichever occurs first. Significant changes shall include, but not be limited to occurrences specified in Section 87463, Reappraisals.
This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review, the licensee did not comply with the section cited above in 2 out of 2 persons which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date:
08/30/2023
Plan of Correction
1
2
3
4
Administrator agrees to complete an updated needs and service plan for R1 and R2. Updated plans to be submitted into CCL by 8/30/23.
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:
Troy Ordonez
TELEPHONE:
(916) 263-4832
LICENSING EVALUATOR NAME:
Bethany Mirlohi
TELEPHONE:
(916) 204-8288
LICENSING EVALUATOR SIGNATURE:
DATE:
08/16/2023
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
08/16/2023
LIC809
(FAS) - (06/04)
Page:
5
of
5