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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 390303860
Report Date: 12/09/2023
Date Signed: 12/10/2023 11:10:32 AM


Document Has Been Signed on 12/10/2023 11:10 AM - 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:
12/09/2023
TYPE OF VISIT:Case Management - Health ChecksUNANNOUNCEDTIME BEGAN:
09:45 AM
MET WITH:Maria Linda EstradaTIME COMPLETED:
11:15 AM
NARRATIVE
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On 12/09/2023, at 9:45am, Licensing Program Analyst (LPA) Arielle Pascua arrived unannounced to 33 N Center St to conduct a health and safety visit. LPA met with Facility Designated Administrator (FDA), Maria Linda Estrada and explained the purpose of the visit.

The purpose of this visit was to conduct a health and safety check. Currently, the facility is undergoing pest control services and do not have any residents at the physical site at this time. As a result, the facilities residents have been relocated to a hotel at this time.
Current census was 10. A brief interview with FDA Estrada was conducted.
The residents have been split between 6 hotel rooms. At this time of the visit it was observed that all residents were in one hotel room watching tv and resting.
LPA conducted a tour of the hotel rooms. LPA reviewed medication and resident files. LPA observed the residents rooms to be clean and sanitary. Main area for resident use was toured and the furniture intended for resident use was observed to be in good repair at this time. LPA observed food supply to be sufficient to meet the residents needs at this time. LPA was told that additional food supply would be brought to the location or food would be ordered and delivered to the residents. The residents were observed to be in good health.
LPA observed that there were only two staff members present at this time. It was agreed upon the department and FDA Estrada that upon relocation there must be 3 staff members on site. LPA reminded FDA Estrada of the agreement. FDA Estrada stated that there are no other staff members available until Monday. LPA and FDA Estrada agreed that current staff will conducting health checks on residents every 15 minutes.
The department will continue to monitor the situations with health and safety checks until the residents are able to return to their primary residence.
Based on the information above, per California Code of Regulations (CCRs) - Title 22, Division 6, Chapter 6, the following deficiencies are being cited on the attached 809D during this visit. If any of the cited deficiencies are not corrected by the noted due dates; civil penalties may be assessed. An exit interview was conducted, and a copy of the report will be given.

SUPERVISOR'S NAME: Lisa RiosTELEPHONE: (916) 969-9685
LICENSING EVALUATOR NAME: Arielle PascuaTELEPHONE: (916) 862-5907
LICENSING EVALUATOR SIGNATURE:
DATE: 12/09/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/09/2023
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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Document Has Been Signed on 12/10/2023 11:10 AM - 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: 12/09/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
12/09/2023
Section Cited
CCR
87411(a)

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(a) Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs. This not met as evidenced by: Based on observation, the Licensee did not ensure that there was sufficient amount of staff to meet the residents needs.
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Administrator stated that there would be a plan put in place to ensure that there is sufficient staff. Administrator stated that current staff will check on the residents every 15 minutes throughout the day. A copy of the plan and a statement of acknowledgement shall be sent to the LPA by the POC date 12/09/2023 by 5pm.
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LPA reminded FDA of the agreement that was put in place between the facility and the department to maintain 3 staff members at all times. This is an immediate health, safety, and personal rights risks to persons 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: Arielle PascuaTELEPHONE: (916) 862-5907
LICENSING EVALUATOR SIGNATURE:
DATE: 12/09/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/09/2023
LIC809 (FAS) - (06/04)
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