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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 390303860
Report Date: 04/07/2021
Date Signed: 04/07/2021 04:32:58 PM



STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
This is an official report of an unannounced visit/investigation of a complaint received in our office on
04/06/2021 and conducted by Evaluator Albert Johnson
COMPLAINT CONTROL NUMBER: 27-AS-20210406104213
FACILITY NAME:OAKHAVENFACILITY NUMBER:
390303860
ADMINISTRATOR:MARIA LINDA ESTRADAFACILITY TYPE:
740
ADDRESS:725 EAST OAK STREETTELEPHONE:
(209) 465-2597
CITY:STOCKTONSTATE: CAZIP CODE:
95202
CAPACITY:15CENSUS: 14DATE:
04/07/2021
UNANNOUNCEDTIME BEGAN:
02:27 PM
MET WITH:Maria EstradaTIME COMPLETED:
04:00 PM
ALLEGATION(S):
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Resident's records are not current
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Albert Johnson conducted an unannounced complaint visit to the facility to investigate and to deliver findings for the above allegations. LPA Johnson was met by the Administrator, Maria Estrada.

Allegation: Resident's records are not current. Based on records reviewed the facility does not have up to date records for three of three resident records reviewed. The facility was actively updating the information in the files of the three residents records reviewed.

The preponderance of evidence standard has been met, therefore the above allegation is found to be substantiated. The following deficiency was observed (see LIC 9099-D) and cited from the California Code of Regulations, Title 22. ..

Failure to correct the deficiency may result in civil penalties.

Appeal rights were provided.

Substantiated
Estimated Days of Completion: 0
SUPERVISOR'S NAME: Stephenie DoubTELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Albert JohnsonTELEPHONE: (916) 217-1390
LICENSING EVALUATOR SIGNATURE:

DATE: 04/07/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/07/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 2
Control Number 27-AS-20210406104213
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: OAKHAVEN
FACILITY NUMBER: 390303860
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/07/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
04/14/2021
Section Cited
CCR
80068.2(b)(1)
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(b) If the client has an existing needs appraisal or individual program plan (IPP) completed by a placement agency, or a consultant for the placement agency...(1) The needs appraisal or IPP is not more than one year old.
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The facility will update Needs and Services Plan for all residents in care. Written certification stating administrator has read regulation 80068.2 along with copies of current needs and service plan for R1, R2 and R3 to be sent to CCLD by POC date
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This requirement is not met as evidenced by:
Based on record review, the licensee failed to maintain a recent or updated copy of R1, R2 and R3's service plan. This poses a potential health and safety risk to residents in care.
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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: Stephenie DoubTELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Albert JohnsonTELEPHONE: (916) 217-1390
LICENSING EVALUATOR SIGNATURE:

DATE: 04/07/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/07/2021
LIC9099 (FAS) - (06/04)
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