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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 347002205
Report Date: 07/18/2024
Date Signed: 07/18/2024 02:29:43 PM


Document Has Been Signed on 07/18/2024 02:29 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:
07/18/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
01:24 PM
MET WITH:Teofil AntonTIME COMPLETED:
02:30 PM
NARRATIVE
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On 7/18/2024, Licensing Program Analyst (LPA) Cassie Yang arrived unannounced at the facility to conduct a case management visit to cite facility for a deficiency observed during annual inspection conducted on 7/11/2024. LPA met with Caregiver who then contacted Administrator who then arrived to the facility moments later. LPA explained the purpose of the visit to Administrator.

During time of visit on 7/11/2024, LPA observed a caregiver working with residents in care. LIC 500 was later submitted to LPA, which confirmed S1 was working at the facility but was not associated to the facility during time of visit. File review on Guardian confirmed that after annual inspection on 7/11/2024, S1 was then associated to the facility on 7/12/2024.

Today's visit, LPA spoke with Administrator who informed LPA that 7/11/2024 was S1's first day. S1 was then associated to the facility a day after visit. LPA was unable to speak with S1 as S1 was off after LPA entered the facility.

Deficiencies cited, please see LIC 809-D. $100 civil penalty assessed.

Exit interview and a copy of the 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: 07/18/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/18/2024
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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Document Has Been Signed on 07/18/2024 02:29 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: 07/18/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
07/19/2024
Section Cited
CCR
87355(e)(2)

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87355 Criminal Record Clearance (e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility: (2) Request a transfer of a criminal record clearance as specified in Section 87355(c)

This requirement is not met as evidenced by:
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S1 is associated to the facility.
Licensee is to submit a statement of understanding that all staff and/or volunteers are to be fingerprint cleared and assocaited to facility roster prior to employment.

Civil penalty assessed of $100.
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Based on file review and observation, LPA observed S1 to be working at the facility on 7/11/2024, file review revealed S1 was associated to the facility on 7/12/2024.
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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: Anthony PerezTELEPHONE: (323) 485-4915
LICENSING EVALUATOR NAME: Cassie YangTELEPHONE: (916) 201-1928
LICENSING EVALUATOR SIGNATURE:
DATE: 07/18/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/18/2024
LIC809 (FAS) - (06/04)
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