<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 390314809
Report Date: 07/22/2022
Date Signed: 07/25/2022 07:24:29 AM


Document Has Been Signed on 07/25/2022 07:24 AM - It Cannot Be Edited

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: 297DATE:
07/22/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:05 AM
MET WITH:Kristalyn Jimenez - Office CoordinatorTIME COMPLETED:
11:45 AM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
 Licensing Program Analyst (LPA) Ruth Wallace conducted a Required 1 year Annual Inspection Visit. LPA also met with Executive Director and explained the purpose of today’s inspection. LPA was allowed entry into the facility that is licensed to serve a total capacity of 499 residents. The facility has 218 residents in Independent Living, 52 in Assisted Living and 27 currently in memory care. The facility has submitted and is following their Mitigation Plan and the focus of this evaluation was on infection control procedures and processes. Administrator Certificate - Dawn Shimel expires 1/23/2023.

LPA toured the facility including but not limited to apartments, bathrooms, kitchen, dining room areas, common area and courtyards. All outdoor and indoor passageways observed were kept free of obstructions. A comfortable temperature throughout the facility is maintained at 74 degrees Fahrenheit. LPA observed lighting in apartments are adequate for the comfort and safety of the residents. Residents’ bathrooms are equipped with grab bars and non-skid floors. There is a minimum of 7-day supply of nonperishable and 2-day of perishable foods. Fire extinguishers were last serviced 3/24/2022 and are in compliance. A Fire Department inspection was completed on 12/17/20 and the facility passed the inspection. The inspection included tests on the alarms on egress doors, fire extinguishers, smoke detectors and alarm system. Emergency Disaster Plan was posted. Hot water temperature was measured at 114.2 F degrees Fahrenheit in resident bathroom sink, which is within the required range of 105 to 120 degrees.
LPA observed centrally stored medications locked inside the medication room. LPA with the assistance of facility Medication Technician reviewed and compared resident medication vs. resident medication logs. LPA reviewed 8 resident and 4 staff files, including criminal record clearances.
All staff today are fingerprint cleared and associated to the facility. First aid kit was checked and is complete. LPA was able to verify last documented fire drill was on 5/12/2022.
LPA received updated copies of the following documents: LIC 308 Designation of Facility Responsibility and current copy of Liability Insurance.

Per California Code of Regulations, Title 22 Division 6, Chapter 8 and Health and Safety Code, No deficiencies were observed. Exit interview held with office coordinator and a report given at the conclusion of the inspection.
SUPERVISOR'S NAME: Stephen RichardsonTELEPHONE: (916) 253-4746
LICENSING EVALUATOR NAME: Ruth WallaceTELEPHONE: (619) 323-4509
LICENSING EVALUATOR SIGNATURE:
DATE: 07/22/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/22/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 1