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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 390303860
Report Date: 10/30/2023
Date Signed: 10/30/2023 03:40:21 PM


Document Has Been Signed on 10/30/2023 03:40 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
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833



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: 13DATE:
10/30/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
01:52 PM
MET WITH:Maria Linda EstradaTIME COMPLETED:
03:45 PM
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On 10-30-23 at 1:52pm, Licensing Program Analysts (LPAs) Michael Bilger and Arvin Villanueva arrived unannounced to conduct a case management visit regarding an incident which occurred on 10-19-23. LPAs met with Administrator Maria Linda Estrada and explained the purpose of the visit. LPAs requested facility file documentation including physician's report for resident1 (R1) and hospital discharge paperwork for R1. LPAs also conducted facility observation and reviewed incident report dated 10-20-23. Additionally, LPAs conducted brief interview with Administrator and staff1 (S1).

Based on incident report and interviews, the following was determined: R1 experienced a fall on 10-19-23 at approximately 12:30pm. S1 went to R1's room upon hearing the scream and observed R1 sitting on the ground. Incident report stated R1 was attempting to sweep floor and fell resulting in pain in R1's right arm and leg. 9-1-1 was contacted and arrived within approximately 15 minutes. R1 was taken to hospital and evaluated. Based on discharge paperwork reviewed and interviews, R1 has a previous diagnosis of a femur fracture which now requires metal plates and screws to be repaired via surgery. Discharge paperwork further revealed that R1 left hospital against medical advise with instructions to return for required surgery. Further record reviews and interviews reveal staffs' attempt to assist R1 with physician follow up appointments and surgery needs

As a result of this case management, no citations are issued today. An exit interview was conducted with Maria Linda Estrada and a copy of this report was provided to Maria.
SUPERVISOR'S NAME: Liza KingTELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Michael BilgerTELEPHONE: 916-862-4722
LICENSING EVALUATOR SIGNATURE:
DATE: 10/30/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/30/2023
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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