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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 390314809
Report Date: 07/16/2024
Date Signed: 07/16/2024 03:19:24 PM


Document Has Been Signed on 07/16/2024 03:19 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:O'CONNOR WOODS ASSISTED LIVINGFACILITY NUMBER:
390314809
ADMINISTRATOR:LEAL-MALLETE, PENNYFACILITY TYPE:
741
ADDRESS:3334 WAGNER HEIGHTS RDTELEPHONE:
(209) 956-3400
CITY:STOCKTONSTATE: CAZIP CODE:
95209
CAPACITY:499CENSUS: 101DATE:
07/16/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Dawn Shimel TIME COMPLETED:
02:00 PM
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Licensing Program Analysts (LPA") Kesha Lewis and Maja Jenson arrived at the facility unannounced for the purpose of conducting a case management incident inspection regarding incident reports received dated 7/8/2024 and 5/21//24 for two resident falls. LPA explained purpose of visit to the administrator.

The incident reports were for two residents that were sent to the hospital. R1 was having pain then sent to hospital were a possible hair line fracture of the knee may be present incident occurred on 5/15/24 and needs and services plane was updated 5/17/24. R2 was sent to hospital on 7/8/24 for an unwitnessed fall needs and services plan was updated on 7/10/24. All RP notified in both incidents.

Per California Code of Regulations, Title 22 no deficiencies were observed and are being cited during today's case management inspection.

An exit interview was conducted and a copy of this report was given.
SUPERVISOR'S NAME: Liza KingTELEPHONE: (650) 676-0442
LICENSING EVALUATOR NAME: Kesha LewisTELEPHONE: (916) 764-1024
LICENSING EVALUATOR SIGNATURE:
DATE: 07/16/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/16/2024
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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