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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 347002205
Report Date: 08/20/2021
Date Signed: 08/20/2021 03:32:08 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 520 COHASSET RD., STE. 170
CHICO, CA 95926
FACILITY NAME:OAK GARDEN SENIOR RESIDENCEFACILITY NUMBER:
347002205
ADMINISTRATOR:ANTON, TEOFILFACILITY TYPE:
740
ADDRESS:6707 SUN DOWN COURTTELEPHONE:
(916) 944-0774
CITY:CARMICHAELSTATE: CAZIP CODE:
95608
CAPACITY:6CENSUS: 6DATE:
08/20/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:30 PM
MET WITH:Administrator, Teofil AntonTIME COMPLETED:
03:45 PM
NARRATIVE
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Licensing Program Analyst (LPA) Melana Llopis arrived at the facility unannounced on 08/20/2021 to conduct a Required - 1 Year inspection. LPA met with Administrator, Teofil Anton and explained the purpose of the visit. Prior to visit, LPA completed required COVID-19 testing protocols, and a daily self-screening questionnaire for symptoms of COVID-19 infection to affirm no COVID-19 related symptoms; upon entry LPA completed a facility risk assessment. LPA ensured they applied hand sanitizer before entering the facility and the following Personal Protective Equipment (PPE) was worn: Surgical Mask. Additionally, LPA was screened by Rodica Anton, staff, upon entering the facility.

LPA and Administrator toured the facility together. Areas inspected include but are not limited to the following:
Kitchen, living room, dinning area, resident bedrooms and bathrooms and backyard. LPA found facility to be odor-free and in good repair. LPA observed sharps, toxins and medications to be locked and inaccessible to residents in care. LPA observed there to be an adequate supply of 7 day nonperishable food items and 2 day perishable food items. LPA found resident bedrooms to have sufficient lighting and required furniture. LPA observed grab bars and nonskid mats in the resident bathrooms. LPA found alert devices to be in working order. LPA observed emergency exit paths to be free of barriers. LPA observed a sufficient supply of clean linens. Smoke detectors and carbon monoxide devices were tested and found in working order. A sufficient supply of PPE was observed. Water temperature was measured at 109 degrees F.
LPA found the fire extinguisher to be serviced last on 06/10/2019 and charged.
LPA found first aid kit to be complete. LPA reviewed infection control procedures with Administrator and found facility to be in compliance with those procedures.

LPA reviewed two (2) of two (2) residents' files in care and found records to be complete.
LPA reviewed staff (S1) and the Administrator's file and found staff are associated and have current first aid and CPR training.
LPA conducted a medication audit for resident (R1) and found no errors.
As a result of today's visit, a deficiency is being cited and can be found on LIC809-D page, per California code of regulations, title 22.

Exit interview conducted, copy of report and appeal rights provided.
SUPERVISOR'S NAME: Maribeth SentyTELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Melana LlopisTELEPHONE: 510-298-7052
LICENSING EVALUATOR SIGNATURE:

DATE: 08/20/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/20/2021
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 520 COHASSET RD., STE. 170
CHICO, CA 95926

FACILITY NAME: OAK GARDEN SENIOR RESIDENCE
FACILITY NUMBER: 347002205
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/20/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87705(c)(5)
87705 Care of Persons with Dementia
(c) Licensees who accept and retain residents with dementia shall be responsible for ensuring the following:
(5) Each resident with dementia shall have an annual medical assessment as specified in Section 87458, Medical Assessment, and a reappraisal done at least annually, both of which shall include a reassessment of the resident’s dementia care needs.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on records review, the licensee did not comply with the section cited above in one (1) out of one (1) persons which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/03/2021
Plan of Correction
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Licensee agrees to schedule a medical assessment visit for resident (R1) and provide proof of appointment schedule and/or visit by POC date provided.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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: Maribeth SentyTELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Melana LlopisTELEPHONE: 510-298-7052
LICENSING EVALUATOR SIGNATURE:
DATE: 08/20/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/20/2021
LIC809 (FAS) - (06/04)
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