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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 347002205
Report Date: 07/11/2024
Date Signed: 07/11/2024 01:13:55 PM


Document Has Been Signed on 07/11/2024 01:13 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 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: 3DATE:
07/11/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:45 AM
MET WITH:Teofil AntonTIME COMPLETED:
01:00 PM
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On 7/11/2024, Licensing Program Analyst (LPA) Cassie Yang and Department of Consumer Affairs Associate Governmental Program Analyst (AGPA) Jessica Vo arrived unannounced at the facility to conduct a required annual inspection utilizing the full care tool. LPA met with Administrator and explained the purpose of the visit.

During today's visit, LPA, AGPA and Administrator conducted a tour of the interior and exterior of the facility. Areas toured included but not limited to: six residents room, two bathroom, kitchen, backyard and the common areas. At arrival in the common areas, LPA and AGPA observed the fire door to popped open with a door stopper. When asked, caregiver informed LPA that door may have been opened for approximately two days. During tour, LPA observed cleaning supply to be stored under the bathroom sink. LPA informed Administrator cleaning supplies are to be locked inaccessible to residents in care, cleaning supply was collected and locked immediately. LPA, AGPA, Administrator continued inspection to the kitchen, and observed the knives and medications to be locked. LPA observed key to cabinet to be store in an conspicuous space. LPA informed Administrator key to locks should be kept where it is inaccessible to residents in care. LPA and Administrator continued inspection to the garage/storage space and observed the area to have a private lock to enter. Once entered, LPA observed the space to have furnitures, clothings and a cooking space. When asked if area is being used as a living quarrel, Administrator informed LPA and AGPA no. When asked why is there furniture in the garage, Administrator informed LPA it is for Administrator to stay in on occasions. When asked if Administrator and his family are living at the facility, Administrator informed LPA no but Administrator stays overnight on occasions for supervision. Tour was continued to the upstairs living space and observed two rooms to be occupied with personal belongings.

LPA informed Administrator inspection is to be continued another day and LPA will reach out to Administrator regarding a mandatory office meeting. Deficiencies cited, please see LIC 809-D.

Exit interview and a copy of report and appeal rights was provided.
SUPERVISOR'S NAME: Anthony PerezTELEPHONE: (323) 485-4915
LICENSING EVALUATOR NAME: Cassie YangTELEPHONE: (916) 201-1928
LICENSING EVALUATOR SIGNATURE:
DATE: 07/11/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/11/2024
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 07/11/2024 01:13 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 GARDEN SENIOR RESIDENCE
FACILITY NUMBER: 347002205

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/11/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87203
87203 Fire Safety All facilities shall be maintained in conformity with the regulations adopted by the State Fire Marshal for the protection of life and property against fire and panic.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above as LPA and AGPA observed fire door to be popped open with a door stopper which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 07/12/2024
Plan of Correction
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Fire door was closed immediately.
Licensee is to submit a statement of compliance, understanding that all fire doors are to be kept closed at all times. POC is due 7/12/2024 to LPA by fax and/or email.
Fire Safety violation, $500 civil penalty assessed.
Type A
Section Cited
CCR
87309(a)
87309 Storage Space
(a) Disinfectants, cleaning solutions, poisons, firearms and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above as LPA observed cleaning supply to be stored under the cabinet with no locks which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 07/12/2024
Plan of Correction
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Cleanng supply was collected and locked immediately.
Licensee is to provide all caregiver a reminder that cleaning supplies are to locked at all times. Licensee is to notify LPA completion of the staff reminder. POC is due 7/12/2024 to LPA by fax and/or email.

Failure to correct by POC may result to $100 per day until corrected.
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: Anthony PerezTELEPHONE: (323) 485-4915
LICENSING EVALUATOR NAME: Cassie YangTELEPHONE: (916) 201-1928
LICENSING EVALUATOR SIGNATURE:
DATE: 07/11/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/11/2024
LIC809 (FAS) - (06/04)
Page: 2 of 2