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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 390314809
Report Date: 08/14/2023
Date Signed: 08/14/2023 04:02:40 PM


Document Has Been Signed on 08/14/2023 04:02 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: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: 85DATE:
08/14/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
02:30 PM
MET WITH:Dawn Shimel TIME COMPLETED:
04:30 PM
NARRATIVE
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On 8/214/23 Licensing Program Analysts (LPA'S) Kesha Lewis and Maja Jensen arrived at facility unannounced to conduct a case management for deficiencies related to theft of a resident's funds. LPA Lewis met with staff and the human resources manager Art Garnica and explained the purpose of today's visit.

On 08/10/23 the facility self reported the theft of a resident's funds by a staff member. The Administrator complied with all reporting requirements within the required time frame. The staff member was terminated. The Administrator notified law enforcement, APS and the Ombudsman.The Administrator also sent an LIC 624, LIC 9060 and completed an SOC 341A.

LPA Lewis requested staff 1's (S1's) personnel file so that the Department can seek an exclusion on the responsible party.

Deficiencies are being cited from the California Code of Regulations, Title 22, Division 6.

An exit interview was conducted and a copy of this report and appeal rights were given to the Administrator.
SUPERVISOR'S NAME: Liza KingTELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Kesha LewisTELEPHONE: (650) 676-0552
LICENSING EVALUATOR SIGNATURE:
DATE: 08/14/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/14/2023
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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Document Has Been Signed on 08/14/2023 04:02 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO AC/SC, 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: 08/14/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
08/15/2023
Section Cited
CCR
87217(b)

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87217 Safeguards for Resident Cash, Personal Property, and Valuables
(b) Every facility shall take appropriate measures to safeguard residents' cash resources, personal property and valuables which have been entrusted to the licensee or facility staff. This requirement was not met as evidenced by:
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The Licensee immediately terminated the employee.The Licensee met with the family of the resident and explained all actions that have been taken. No other victims have been identified. No further Plan of Correction is required.
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Based on the facility's self reporting, a staff member used a resident's credit card to place online orderss. This poses a potential health, safety and 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: Liza KingTELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Kesha LewisTELEPHONE: (650) 676-0552
LICENSING EVALUATOR SIGNATURE:
DATE: 08/14/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/14/2023
LIC809 (FAS) - (06/04)
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