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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 390303860
Report Date: 11/14/2023
Date Signed: 11/14/2023 04:45:26 PM


Document Has Been Signed on 11/14/2023 04:45 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 AC/SC, 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: 12DATE:
11/14/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Maria Linda Estrada and Maria Nelina EstradaTIME COMPLETED:
03:30 PM
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Unannounced case management visit made out to this facility on 11/14/2023 by Licensing Program Analyst (LPA) Charlie Yang who was met by the facility caregiver, Maria Nelina Estrada, and the facility designated Administrator, Maria Linda Estrada, who were both briefly interviewed.
Current census was 12 residents.
The purpose of this visit was to follow up on an incident that was reported into CCL in regards to resident R1.

The following forms and documents were requested by this LPA solely for resident R1:
  • LIC 602

  • LIC 604

  • ID/Emergency information

  • Needs and Appraisal

  • Any, and all, LIC 624s since admission

  • Medication Administration Record

  • Medication dispensing log


There were no deficiencies observed or cited during today's case management visit.

Exit Interview
SUPERVISOR'S NAME: Liza KingTELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Charlie YangTELEPHONE: (916) 263-4700
LICENSING EVALUATOR SIGNATURE:
DATE: 11/14/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/14/2023
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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