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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 390303860
Report Date: 05/15/2024
Date Signed: 05/15/2024 12:45:14 PM


Document Has Been Signed on 05/15/2024 12:45 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: 1DATE:
05/15/2024
TYPE OF VISIT:Case Management - Legal/Non-complianceUNANNOUNCEDTIME BEGAN:
10:45 AM
MET WITH:Maria Linda EstradaTIME COMPLETED:
01:00 PM
NARRATIVE
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On 5-15-24 at 10:45am, Licensing Program Analyst (LPA) Michael Bilger arrived unannounced to conduct a quarterly health and safety check. LPA met with Licensee Maria Linda Estrada and facility manager and explained the purpose of the visit. LPA observed facility premises including living room area, dining room area, hallways, kitchen area, resident bedrooms, bathrooms, and outside area of facility. Facility's current census is 1. LPA observed facility to be clean and sanitary throughout with no foul odors,

LPA did not observe evidence of bed bugs or head lice. Facility maintains on-going pest control services. Medication log sheets were reviewed for accuracy. Records reviewed revealed staff assist resident with medications as prescribed. Staff files were also reviewed for completeness. Staff files reviewed revealed 20 hours of annual training not completed. Additionally, staff first aid training is expired as of 5-9-24. Facility is continuing with the closure process pending the appropriate discharge of remaining resident in care.

As a result of today's inspection, citations are issued under Title 22, Division 6 and Health and Safety Codes.. The Department will continue to perform quarterly health and safety visits as noted in the original report dated 2-1-2024. 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: 05/15/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/15/2024
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 05/15/2024 12:45 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: 05/15/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
05/28/2024
Section Cited
HSC
1569.625(b)(2)

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Staff training; legislative findings; contents. (b) (2) In addition to paragraph (1), training requirements shall also include an additional 20 hours annually, eight hours of which shall be dementia care training, as required by subdivision (a) of Section 1569.626, and four hours of which shall be specific to postural supports, restricted health conditions, and hospice care, as required by subdivision (a) of Section 1569.696. This training shall be administered on the job, or in a classroom setting, or both, and may include online training. This requirement was not met as evidenced by:
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Licensee will ensure completeness of 20 hour annual training for all staff and submit proof of completed training by POC due date.

Licensee will read regulation 1569.625 and submit a signed declaration of understanding to LPA by POC due date.
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Based on record review, 2 of 2 staff have not completed and updated 20 hours of annual training. This poses a potential health and safety risk to residents in care.
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Type B
05/20/2024
Section Cited
CCR87411(c)(1)

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Personnel Requirements. (c)All RCFE staff who assist residents with personal activities of daily living shall receive initial and annual training as specified in Health and Safety Code sections 1569.625 and 1569.69 (1)Staff providing care shall receive appropriate training in first aid from persons qualified by such agencies as the American Red Cross. This requirement was not met as evidenced by:
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Licensee will ensure the updated re-certification of first aid and CPR training for staff and send proof of completed training to LPA by POC due date.
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Based on record review, 2 of 2 staff have expired first aid and CPR training certificates on file. 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: Liza KingTELEPHONE: (650) 676-0442
LICENSING EVALUATOR NAME: Michael BilgerTELEPHONE: (916) 862-4722
LICENSING EVALUATOR SIGNATURE:
DATE: 05/15/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/15/2024
LIC809 (FAS) - (06/04)
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