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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 390314809
Report Date: 02/09/2021
Date Signed: 02/09/2021 03:08:14 PM

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: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: 324DATE:
02/09/2021
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
02:45 PM
MET WITH:Telephone Call -Administrator - Dawn Shimel Due to COVID-19 PrecautionsTIME COMPLETED:
03:15 PM
NARRATIVE
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Licensing Program Analyst (LPA) Ruth Wallace contacted the facility on this day via telephone to conduct a Case Management - Deficiency Visit. This visit was conducted by telephone lieu of a physical visit due to the current COVID-19 precautions. LPA spoke with Administrator (AD) Dawn Shimel and explained the purpose of the visit.

There have been two unsubstantiated complaints concluded on 2/14/20 and 10/14/20 with allegations that facility did not safeguarding residents' personal belongings. During the investigations LPA's have determined the Policy For Theft/Loss for residents belongings and the inventory sheet were not completed properly for the time period residents were in facility.

As a result of today's case management, one deficiency is cited on the attached 809-D page. Deficiency issued in accordance with Health and Safety Code and/or California Code of Regulations Title 22.

An exit interview was conducted with Administrator and a copy of this report was provided to Administrator via email. An electronic response from Administrator confirms receipt of this report.
SUPERVISOR'S NAME: Stephen RichardsonTELEPHONE: (916) 253-4746
LICENSING EVALUATOR NAME: Ruth WallaceTELEPHONE: (619) 323-4509
LICENSING EVALUATOR SIGNATURE:

DATE: 02/09/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/09/2021
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
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

FACILITY NAME: O'CONNOR WOODS ASSISTED LIVING
FACILITY NUMBER: 390314809
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/09/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
02/23/2021
Section Cited

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87218 (a)(1) Theft and Loss
The licensee shall ensure an adequate theft and loss program as specified in Health and Safety Code Section
The initial personal property inventory shall be completed by the licensee, and the resident, or the resident’s representative.
This requirement was not met as evidenced by:
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Based on interviews and documentation obtained by LPA's the Licensee did not properly inventory the personal property of residents.
This poses a potential personal rights risk to residents in care.
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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: Stephen RichardsonTELEPHONE: (916) 253-4746
LICENSING EVALUATOR NAME: Ruth WallaceTELEPHONE: (619) 323-4509
LICENSING EVALUATOR SIGNATURE:
DATE: 02/09/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/09/2021
LIC809 (FAS) - (06/04)
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