390303860-5-15-2024-27-AS-MBIR-D5AURM-20240515154858

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 390303860
Report Date: 05/15/2024
Date Signed: 05/15/2024 03:49:04 PM

Document Has Been Signed on 05/15/2024 03:49 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:	OAKHAVEN		FACILITY NUMBER:	390303860
ADMINISTRATOR:	MARIA LINDA ESTRADA		FACILITY TYPE:	740
ADDRESS:	725 EAST OAK STREET		TELEPHONE:	(209) 465-2597
CITY:	STOCKTON	STATE: CA	ZIP CODE:	95202
CAPACITY:	15	CENSUS: 1	DATE:	05/15/2024
TYPE OF VISIT:	Case Management - Incident	UNANNOUNCED	TIME BEGAN:	02:45 PM
MET WITH:	Maria Linda Estrada		TIME COMPLETED:	04:00 PM

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On 5-15-24 at 2:45pm, Licensing Program Analyst (LPA) Michael Bilger arrived unannounced to conduct a case management visit regarding a previous department investigation of a death of a resident following an absence of leave incident (AWOL). LPA met with Licensee Maria Linda Estrada and explained the purpose of the visit. During this investigation, the Department conducted interviews with Licensee and staff1 (S1) as well as resident2 (R2), R3, and R4. Department also reviewed facility file and other documentation pertaining to resident1 (R1) including physician’s report, police report, medical examiner’s report, and toxicology report.

Based on interviews conducted, it was determined that on 11-1-23, R1 got up at approximately 8am and ate breakfast. Between 12:00pm and 12:30pm, Licensee went to R1’s room to inform him of lunch and discovered R1 was not in his room. Licensee then inquired with other residents at the dining table where R1 may be and was told by another resident that R1 was seen walking by himself down the side street at approximately 10:00am. Licensee then drove around neighborhood between approximately 12:00pm and 1:00pm to look for R1 but was unable to locate him. At approximately 2:00pm, Licensee contact local law enforcement to report a missing person. On 11-11-23, Licensee was contacted by the Office of Medical Examiner and was told R1 was found deceased in a nearby park. Interviews further revealed R1 did not have a previous history of absence without leave (AWOL). Interviews with R2, R3, and R4 revealed an unknown reason why R1 left facility and did not reveal anything was said by R1 prior to leaving.

Physician’s report reviewed states R1 was able to leave facility unassisted. Police report reviewed states that on 11-10-23 R1 was found lying on his side near what appeared to be vomit. Police report further states no evidence of foul play. R1 was pronounced deceased by medics at 5:30pm. A review of the Office of Medical Examiner report states the cause of death was Idiopathic Lethal-Cardiac Arrhythmia and the manner of death was natural.

SUPERVISOR'S NAME: Liza King	TELEPHONE: (650) 676-0442
LICENSING EVALUATOR NAME: Michael Bilger	TELEPHONE: (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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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
	VISIT DATE: 05/15/2024

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A review of toxicology report revealed “no common acidic, neutral, or basic drugs detected. No Ethyl Alcohol detected.” This same report stated R1 was negative for "Cannabinoids (THC metabolite) by Immunoassay."

As a result of this investigation, the Department has determined no substantiated evidence of neglect/lack of supervision resulting in the death of R1. No citations are issued as a result of today’s case management, and case management has been closed. An exit interview was conducted with Maria Linda Estrada, and a copy of this report was provided to Maria.

SUPERVISOR'S NAME: Liza King	TELEPHONE: (650) 676-0442
LICENSING EVALUATOR NAME: Michael Bilger	TELEPHONE: (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

LIC809 (FAS) - (06/04)

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