390303860-11-9-2023-27-AS-LRIS-CXMP4L-20231116095919

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 390303860
Report Date: 11/02/2023
Date Signed: 11/09/2023 10:37:13 AM

Substantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

This is an official report of an unannounced visit/investigation of a complaint received in our office on
09/13/2023 and conducted by Evaluator Albert Johnson

PUBLIC

COMPLAINT CONTROL NUMBER: 27-AS-20230913140759

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: 13	DATE:	11/02/2023
		UNANNOUNCED	TIME BEGAN:	09:46 AM
MET WITH:	M. Estrada		TIME COMPLETED:	12:32 PM

ALLEGATION(S):

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Facility staff failed to provide supervision to resident.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Albert Johnson arrived and met with Maria Estrada to deliver findings

Based on the reported incident and interview with the Admininstrator the facility did not meet the needs of R1.

The incident report detailed that R1 had been stuck on her knees, and could not help herselves to her feet for a reported two hours. R1 had an alter level of consiouness, was incontinent and in pain from being stuck for two hours on her knees. R1 was transported to Dameron Hospital and did not return to the facility. Continued

Substantiated

Estimated Days of Completion: 0

SUPERVISOR'S NAME: Stephenie Doub	TELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Albert Johnson	TELEPHONE: (916) 217-1390
LICENSING EVALUATOR SIGNATURE:	DATE: 11/02/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/02/2023

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 27-AS-20230913140759

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

FACILITY NAME: OAKHAVEN	FACILITY NUMBER: 390303860
	VISIT DATE: 11/02/2023

NARRATIVE

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The facility assumes responsibility for, or provides or promises to provide in the future, ongoing assistance with activities of daily living without which the resident’s physical health, mental health, safety, or welfare would be endangered. Assistance includes assistance with taking medications, money management, or personal care. As a result of this incident the facility did not meet R1's basic needs for personal care.

Based on interviews conducted the preponderance of evidence standards has been met, therefore, the above allegation(s) is found to be SUBSTANTIATED. Per California Code of Regulations, Title 22 Division 6, Chapter 8, deficiencies are being cited on the attached 9099D during this visit. Exit interview held, Appeal Rights discussed, Copy of report given.

SUPERVISOR'S NAME: Stephenie Doub	TELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Albert Johnson	TELEPHONE: (916) 217-1390
LICENSING EVALUATOR SIGNATURE:	DATE: 11/02/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/02/2023

LIC9099 (FAS) - (06/04)

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Control Number 27-AS-20230913140759

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

FACILITY NAME: OAKHAVEN	FACILITY NUMBER: 390303860
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 11/02/2023

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 11/03/2023 Section Cited CCR 87464(f)(1)(2)	1 2 3 4 5 6 7	(f) Basic services shall at a minimum include: (1) Care and supervision as defined in Section 87101(c)(3) and Health and Safety Code section 1569.2(c).	1 2 3 4 5 6 7	The Facility will conduct an all staff in-service training on Basic Services and night supervision. The facility will provide the department with a plan to have a staff available to assist residents in the evening.
	8 9 10 11 12 13 14	(2)Safe and healthful living accommodations and services, as specified in Section 87307, Personal Accommodations and Services. This requirement was not met as evidence by interviews conducted and report submitted incident report detailed that R1 had been stuck on her knees, and could not help herselves to her feet for a reported two hours. R1 had an alter level of consiouness, was incontinent and in pain from being stuck for two hours. The posed a health and safety risk to the resident in care.	8 9 10 11 12 13 14	The plan shall be submitted by the POC date 11/3/2023
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

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: Lisa Rios	TELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Albert Johnson	TELEPHONE: (916) 217-1390
LICENSING EVALUATOR SIGNATURE:	DATE: 11/02/2023

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/02/2023

LIC9099 (FAS) - (06/04)

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