347002810-11-16-2023-27-AS-AVIA-CXMSKR-20231116125711

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 347002810
Report Date: 11/16/2023
Date Signed: 11/16/2023 12:57:17 PM

Document Has Been Signed on 11/16/2023 12:57 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:	OAKS FAMILY CARE		FACILITY NUMBER:	347002810
ADMINISTRATOR:	MIN, OKGI		FACILITY TYPE:	740
ADDRESS:	9456 BLUE DIAMOND WAY		TELEPHONE:	(916) 714-1796
CITY:	ELK GROVE	STATE: CA	ZIP CODE:	95624
CAPACITY:	6	CENSUS: 4	DATE:	11/16/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	10:00 AM
MET WITH:	Okgi Min		TIME COMPLETED:	01:00 PM

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On 10/16/2023 at 10 am Licensing Program Analyst (LPA) Arvin Villanueva arrived at this facility unannounced to conduct a required annual inspection visit. LPA met the administrator in record Okgi Min and explained the purpose of the visit. Per administrator, facility is COVID-free status. Present during this visit are 4 residents in care and 1 staff members on duty.

At 10:30am LPA and administrator toured the physical plant including but not limited to the kitchen, dining room, resident bedrooms; resident bathrooms, laundry room, living area, garage, other common areas, and outside of the facility to ensure compliance with Title 22 regulations. Facility is a single-story home with a fire clearance to serve 6 non-ambulatory elderly residents. Facility is approved for 3 hospice residents and fire cleared for 2 bedridden residents (in rooms 1 and 2). Facility has 5 resident bedrooms and 2 and 1/2 bathrooms for resident use. Currently, 4 of the bedrooms are being occupied. LPA observed all bathrooms to contain grab bars, non-skid flooring, shower chairs, close lid trash containers and hygiene supplies. Resident bedrooms were sanitary, furnished, well-lit and had adequate storage for resident’s belongings.

The facility common areas are cleaned and furnished. LPA observed the kitchen to be sanitary and free of clutter. Additionally, the kitchen knives and other sharp objects are kept in a locked drawer. Toxins and cleaning supplies are kept locked. LPA observed the facility to have adequate food supply with at least 2 days’ worth of perishables and 7 days’ worth of non-perishables. LPA observed the garage with 2 additional fridges for food storage, and functioning washer and dryer.

LPA observed the dining room to be free of clutterl. The front yard and the backyard are observed to be free of obstruction and well-maintained. Additionally, the backyard is furnished with outdoor furniture for outdoor activities. Water temperature reads 105*F to 120*F in one of the bathrooms and room temperature reads 74*F. Smoke and carbon detectors were in good working condition. Fire extinguisher was serviced on 7/31/23. Medication storage area was observed to be locked and inaccessible to residents in care. Medication records were reviewed and in compliance with regulation. First aid kit was observed to have adequate supplies and accessible to staff. {Con't on LIC809-C}

SUPERVISOR'S NAME: Stephen Richardson	TELEPHONE: (916) -26-4700
LICENSING EVALUATOR NAME: Arvin Villanueva	TELEPHONE: 916-558-2130
LICENSING EVALUATOR SIGNATURE:	DATE: 11/16/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/16/2023

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
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: OAKS FAMILY CARE	FACILITY NUMBER: 347002810
	VISIT DATE: 11/16/2023

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{Con't from LIC809}

During this inspection 4 out of 4 resident files and 3 staffing files were reviewed for regulatory compliance. All files contained required contents including staff training requirements. All staff noted on LIC 500 contained criminal background clearances. Resident files reviewed contained all required contents including updated admission agreements, medical assessments, and updated appraisal forms as required. Facility’s liability insurance is current and update to date per regulatory requirements. LPA observed personal rights poster. Facility has appropriate internet access available for resident use. LPA observed sufficient equipment and supplies to meet activity program needs of residents in care. LPA reviewed facility’s disaster plan to ensure regulatory compliance. LPA's record review revealed evidence of quarterly fire drills.

LPA also conducted the inspection using the CARE tool. The facility has an approved infection control plan in place. LPA requested an updated copy of Liability Insurance, facility sketch, LIC 308 and LIC 500.

Per California Code of Regulations, Title 22 and Health and Safety Codes, no deficiencies were observed during this visit. Interview was held with the Okgi Min and a copy of this report and appeal rights were provided.

SUPERVISOR'S NAME: Stephen Richardson	TELEPHONE: (916) -26-4700
LICENSING EVALUATOR NAME: Arvin Villanueva	TELEPHONE: 916-558-2130
LICENSING EVALUATOR SIGNATURE:	DATE: 11/16/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/16/2023

LIC809 (FAS) - (06/04)

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