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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 390303860
Report Date: 12/08/2023
Date Signed: 12/08/2023 03:14:21 PM


Document Has Been Signed on 12/08/2023 03:14 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: 10DATE:
12/08/2023
TYPE OF VISIT:Case Management - Health ChecksUNANNOUNCEDTIME BEGAN:
02:05 PM
MET WITH:Maria Linda EstradaTIME COMPLETED:
03:30 PM
NARRATIVE
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On 12-8-23 at 2:05pm, Licensing Program Analyst (LPA) Michael Bilger arrived unannounced to conduct a case management regarding health and safety. LPA met with Maria Linda Estrada and explained the purpose of the visit. LPA conducted brief interview with resident1 (R1) and reviewed physician's visit report dated 11-20-23. During today's visit, it was determined that R1 had an instance of head lice on 11-20-23 and was prescribed medication Ivermectin 0.5% topical lotion which facility did not obtain and instead utilized an over the counter shampoo for head lice. As a result, R1 did not receive prescribed treatment initiated on 11-20-23. Licensee agrees to contact R1's physician and arrange for necessary treatment.

At this time, R1 is the sole resident at facility. LPA observed adequate food supply on hand as well as various clothing in bags. R1 has access to clothing and other personal items at this time as well as medications. The additional residents are currently relocated at this time due to pest control services.

As a result of today's visit, citations are issued under Title 22, Division 6. An exit interview was conducted with Maria Linda Estrada and a copy of this report was provided to Maria. Appeal rights provided.
SUPERVISOR'S NAME: Liza KingTELEPHONE: (650) 676-0442
LICENSING EVALUATOR NAME: Michael BilgerTELEPHONE: (916) 862-4722
LICENSING EVALUATOR SIGNATURE:
DATE: 12/08/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/08/2023
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 12/08/2023 03:14 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: 12/08/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
12/11/2023
Section Cited
CCR
87465(a)(4)

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Incidental Medical and Dental Care. (a) A plan for incidental medical and dental care shall be developed by each facility...(4) The licensee shall assist residents with self-administered medications as needed. This requirement was not met as evidenced by:
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Licensee will arrange for medication to be available for R1 and noted on medication log sheets. Arrangement to include but not be limited to: Physician's appointments, communication with pharmacy. Proof of medication on hand to be submitted to LPA by POC due date.
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Based on interview and record review, Licensee did not ensure R1 receive a prescribed medication for head lice, which posed an immediate health and safety risk to residents in care.
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Type B
12/18/2023
Section Cited
CCR87211(a)(1)(D)

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Reporting Requirements. (a) Each licensee shall furnish to the licensing agency such reports...(1) A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence...(D) Any incident which threatens the welfare, safety or health of any resident. This requirement was not me as evidenced by:
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Licensee will read regulation 87211 and submit a signed declaration of understanding to LPA by POC due date.
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Based on interview and record review, Licensee did not ensure a written report to licensing agency regarding an occurrence of a resident obtaining head lice, which posed 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: Liza KingTELEPHONE: (650) 676-0442
LICENSING EVALUATOR NAME: Michael BilgerTELEPHONE: (916) 862-4722
LICENSING EVALUATOR SIGNATURE:
DATE: 12/08/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/08/2023
LIC809 (FAS) - (06/04)
Page: 2 of 2