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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342701211
Report Date: 01/30/2024
Date Signed: 01/30/2024 03:19:35 PM

Document Has Been Signed on 01/30/2024 03:19 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 SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME:STEWART OAKS VILLAFACILITY NUMBER:
342701211
ADMINISTRATOR:FERREIRA, MELANIEFACILITY TYPE:
740
ADDRESS:1099 STEWART ROADTELEPHONE:
(916) 222-1010
CITY:SACRAMENTOSTATE: CAZIP CODE:
95864
CAPACITY: 6CENSUS: 6DATE:
01/30/2024
TYPE OF VISIT:Case Management - Health ChecksUNANNOUNCEDTIME BEGAN:
01:25 PM
MET WITH:Melanie Ferreira and Jennifer CamposTIME COMPLETED:
02:45 PM
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Licensing Program Analyst (LPA) Pang Lee arrived unannounced on 01/30/2024 at 1:25 PM to conduct a health and safety case management visit. The facility is on quarterly visits due to non-compliance concerns discussed during a zoom meeting on 10/16/2023. LPA Lee met with administrator Melanie Ferreira and house Manager Jennifer Campos and explained the purpose of the visit. The census is 6 with 4 facility staff during today’s visit.

At 1:25 PM, LPA Lee entered the facility, LPA Lee observed three residents sitting in the common area watching TV and another resident in the kitchen getting yogurt. LPA Lee observed one care staff working on resident’s care notes and another care staff doing laundry. LPA Lee spoke to 2 residents. All residents observed today appeared to be clean and comfortable. At 2:05 PM, LPA Lee toured the physical plant to ensure compliance with Title 22 regulations. LPA Lee observed resident bedrooms, bathrooms, common areas, exterior plants, garage, and storage shed. LPA Lee also observed body of water was locked. LPA Lee also observed resident bedrooms to have the necessary furniture and furnishings. Bedrooms were equipped with a bed, chair, dresser, and closet space. Resident bathrooms were stocked with toilet paper, paper towels, and soap. Resident bathroom also had handrails and non-slip mat. The temperature inside the home is 70 degrees Fahrenheit. The hot water temperature was measured at 116.2 degrees Fahrenheit. LPA Lee observed the fire extinguisher located in the kitchen. The fire extinguisher was last serviced on 12/07/2023. The carbon monoxide and fire alarm observed to be working and in good repair. LPA Lee observed no emergency exits were obstructed. LPA Lee observed chemicals and knives were made inaccessible to residents in care. LPA requested to review resident files and staff files. LPA Lee reviewed 3 out of 6 resident files and 3 staff files and they were all complete. LPA Lee reviewed and compared 3 out of 6 medication administration records (MAR) and it was complete and accurate. The first aid kit was checked and contained all the required components.

Per California Code of Regulations, Title 22, no deficiencies were observed during this visit. An exit interview was conducted, and a copy of this report was provided.
SUPERVISORS NAME: Czarrina A Camilon-Lee
LICENSING EVALUATOR NAME: Pang Lee
LICENSING EVALUATOR SIGNATURE: DATE: 01/30/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/30/2024
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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