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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 390303860
Report Date: 11/29/2023
Date Signed: 12/04/2023 10:31:06 PM


Document Has Been Signed on 12/04/2023 10:31 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:OAKHAVENFACILITY NUMBER:
390303860
ADMINISTRATOR:MARIA LINDA ESTRADAFACILITY TYPE:
740
ADDRESS:725 EAST OAK STREETTELEPHONE:
(209) 465-2597
CITY:STOCKTONSTATE: CAZIP CODE:
95202
CAPACITY:15CENSUS: 12DATE:
11/29/2023
TYPE OF VISIT:POCUNANNOUNCEDTIME BEGAN:
01:51 PM
MET WITH:Maria Linda EstradaTIME COMPLETED:
03:30 PM
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LPA Albert Johnson made an unannounced Plan Of Correction(POC) visit to the facility to verify correction of citations issued during the complaint investigation on 11/02/2023.

Deficiency cited under Title 22 Regulations have not been cleared. Licensee did not complied with the terms of the POC by POC due date. The facility will be recited for this failure to correct and additional time will not be granted to address this matter. The facility was given time to correct this issue and has not completed the plan.

The substantiated allegation will be recited on the attached 809D page.

Failure to submit Proof of Corrections (POC's) by plan of correction due dates will result in civil penalties.

Exit interview conducted and appeal rights given
SUPERVISOR'S NAME: Lisa RiosTELEPHONE: (916) 969-9685
LICENSING EVALUATOR NAME: Albert JohnsonTELEPHONE: (916) 217-1390
LICENSING EVALUATOR SIGNATURE:
DATE: 11/29/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/29/2023
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 12/04/2023 10:31 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 SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827


FACILITY NAME: OAKHAVEN
FACILITY NUMBER: 390303860

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/29/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
11/30/2023
Section Cited
CCR
87303(a)

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87303(a) Maintenance and Operation. The facility shall be clean, safe, sanitary and in good repair at all times.
This requirement is not met as evidenced by:
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The licensee shall have a certified pest control company conduct a facility-wide bedbug treatment. The licensee shall send proof/invoice of bedbug inspection/treatment to LPA via email by 11/30/2023 The licensee shall conduct routine pest control inspections to minimize the outbreak of future Lice or bedbugs
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Based on observation, interviews, and record review, the licensee did not maintain the facility in a clean and sanitary condition. The facility currently has evidence of bedbugs and Lice.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: Lisa RiosTELEPHONE: (916) 969-9685
LICENSING EVALUATOR NAME: Albert JohnsonTELEPHONE: (916) 217-1390
LICENSING EVALUATOR SIGNATURE:
DATE: 11/29/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/29/2023
LIC809 (FAS) - (06/04)
Page: 2 of 2