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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 390303860
Report Date: 12/10/2023
Date Signed: 12/11/2023 07:34:57 AM


Document Has Been Signed on 12/11/2023 07:34 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:
12/10/2023
TYPE OF VISIT:Case Management - Health ChecksUNANNOUNCEDTIME BEGAN:
09:45 AM
MET WITH:Maria EstradaTIME COMPLETED:
11:15 AM
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On 12/10/2023, Licensing Program Analyst (LPA) Arielle Pascua arrived unannounced to to 33 N Center St to conduct a health and safety visit. LPA met with Facility Designated Representative (FDR), Maria Nelina Estrada and explained the purpose of the visit. There were three other staff members were present at that the facility, Facility Designated Administrator (FDA), Maria Linda Estrada, Celina Estrada, and April Estrada.
Current census was 10.
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.
The residents have been split between 6 hotel rooms. At this time of the visit it was observed that all residents were in their respective hotel rooms 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 staff members actively checking resident rooms during this visit. LPA observed staff members providing residents with a new set of clothing and ensuring that their needs were being met. Staff will ensure that residents are checked every 30 minutes.
LPA observed staff members provide snacks, and cereal during this visit. LPA was informed that a meal plan was created to ensure that all residents are provided breakfast, lunch, dinner and snacks. 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 observations during this visit, there are no deficiencies cited during this visit. An exit interview was conducted and a copy of this report was provided.
SUPERVISOR'S NAME: Lisa RiosTELEPHONE: (916) 969-9685
LICENSING EVALUATOR NAME: Arielle PascuaTELEPHONE: (916) 862-5907
LICENSING EVALUATOR SIGNATURE:
DATE: 12/10/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/10/2023
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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