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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 037002697
Report Date: 04/11/2023
Date Signed: 04/11/2023 03:19:41 PM


COMPREHENSIVE INSPECTION

Document Has Been Signed on 04/11/2023 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
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833



FACILITY NAME:OAK MANOR SENIOR RETIREMENT HOMEFACILITY NUMBER:
037002697
ADMINISTRATOR:NATALIYA REGANFACILITY TYPE:
740
ADDRESS:223 NEW YORK RANCH ROADTELEPHONE:
(209) 223-3273
CITY:JACKSONSTATE: CAZIP CODE:
95642
CAPACITY:70CENSUS: 34DATE:
04/11/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:58 AM
MET WITH:N. ReganTIME COMPLETED:
03:44 PM
NARRATIVE
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Licensing Program Analyst (LPA) Albert Johnson arrived unannounced to conduct an annual inspection. LPA met with the Administrator and explained the purpose of the visit.

LPA inspected the physical plant including but not limited to the kitchen, dining room, resident bedrooms; resident bathrooms, laundry room, activity room, and outside courtyards. LPA observed sufficient furniture and lighting throughout the facility. LPA observed sufficient seven day non-perishable and two day perishable food supplies. Hot water temperature was measured in resident bathroom sink
(RM 104), which is within the required range of 105 to 120 degrees.

Fire extinguishers and smoke detectors are operational. LPA was unable to determine when the last fire drill was conducted. LPA observed centrally stored medications are kept locked and inaccessible to residents. LPA reviewed and compared resident medication vs. resident medication logs. LPA reviewed 12 resident and 7 staff files, including criminal record clearances.

First aid kit was checked and is complete. LPA observed carbon monoxide detectors in the facility. Deficiencies were cited pursuant to Title 22 rules and regulations, Health and Safety Codes.

Exit interview conducted and appeal rights given.
SUPERVISOR'S NAME: Stephenie DoubTELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Albert JohnsonTELEPHONE: (916) 217-1390
LICENSING EVALUATOR SIGNATURE:
DATE: 04/11/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/11/2023
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 04/11/2023 03:19 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
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833


FACILITY NAME: OAK MANOR SENIOR RETIREMENT HOME
FACILITY NUMBER: 037002697

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/11/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
04/12/2023
Section Cited

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87705(I)(8) Care of Persons with Dementia. Fire and earthquake drills shall be conducted at least once every three months on each shift and shall include, at a minimum, all direct care staff.
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The facility shall develop and implement a policy regarding fire drill and earthquake drill practices and procedures that include conducting fire drills at least once every three months on each shift and shall include, at a minimum, all direct care staff.
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This requirement is not met based on: LPA was unable to determine when the facility conducted a disaster/fire drill. There was no documentation in the facility during the inspection today, which is an immediate risk to residents in care.
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Type A
04/12/2023
Section Cited

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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.
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The facility will have the sprinkler system serviced or have the sticker updated to reflect current compliance with the Fire Marshal by POC dated 4/12/2023. Please send a photo of the updated sticker.
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This requirement is not met as evidenced by: Based on observation the sticker for the annual compliance is dated 2019. The system sticker is out of compliance for the annual inspection or service this poses a potential health and safety risk to the residents in care
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Civil penalty assessed.

The facility is in the process of having repairs completed for the sprinklers. There is no completion date.
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: Stephenie DoubTELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Albert JohnsonTELEPHONE: (916) 217-1390
LICENSING EVALUATOR SIGNATURE:
DATE: 04/11/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/11/2023
LIC809 (FAS) - (06/04)
Page: 2 of 2