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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 390303860
Report Date: 12/13/2023
Date Signed: 12/13/2023 03:14:26 PM


Document Has Been Signed on 12/13/2023 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: 9DATE:
12/13/2023
TYPE OF VISIT:Case Management - Health ChecksUNANNOUNCEDTIME BEGAN:
01:15 PM
MET WITH:April DiazTIME COMPLETED:
02:45 PM
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On 12/13/2023, Licensing Program Analyst (LPA) Kesha Lewis arrived unannounced to 33 N Center St to conduct a health and safety visit. LPA met with caregiver April Diaz 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 9 as one resident had been taken to the hospital for evaluation R1. A brief interview with caregiver April was conducted. The residents have been split between 6 hotel rooms. At this time of the visit it was observed that all residents were their own room tv and/or 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 but there is a menu as a guide. The residents were observed to be in good health.

The department will continue to monitor the situations with health and safety checks until the residents are able to return to their primary residence. Staff will ensure that residents are checked every 30 minutes.

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: Liza KingTELEPHONE: (650) 676-0442
LICENSING EVALUATOR NAME: Kesha LewisTELEPHONE: (916) 764-1024
LICENSING EVALUATOR SIGNATURE:
DATE: 12/13/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/13/2023
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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