390314809-8-14-2023-27-AS-KLES-CUPUWE-20230814155638

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 390314809
Report Date: 08/14/2023
Date Signed: 08/14/2023 03:56:43 PM

Document Has Been Signed on 08/14/2023 03:56 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 LIVING		FACILITY NUMBER:	390314809
ADMINISTRATOR:	LEAL-MALLETE, PENNY		FACILITY TYPE:	741
ADDRESS:	3334 WAGNER HEIGHTS RD		TELEPHONE:	(209) 956-3400
CITY:	STOCKTON	STATE: CA	ZIP CODE:	95209
CAPACITY:	499	CENSUS: 85	DATE:	08/14/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:45 AM
MET WITH:	Dawn Shimel		TIME COMPLETED:	05:00 PM

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Licensing Program Analysts (LPA'S) Kesha Lewis and Maja Jenson arrived at this facility unannounced to conduct a Required 1 Year Annual Inspection Visit. LPA'S were met by Staff member and Assisted living manager joined 15 minutes later. LPA explained the purpose of the visit to staff and assisted living manager.

LPA'S and staff inspected the physical plant including but not limited to the kitchen, dining room, resident bedrooms; resident bathrooms, laundry area, living area and other common areas, as well as outside of the facility to ensure compliance with Title 22 regulations. The facility is a two story building there are two buildings for the assisted living. Currently the facility has a current census of 85. There is entry door is leading to a common area living room, kitchen with a hallway to the bedrooms and bathrooms. The hallway has COVID precautions in place including social distancing noted. Chemicals and medications noted to be locked to residents in care. LPA also conducted the care tool.

Hot water temperature was measured at 120 F degrees Fahrenheit in resident bathroom sink, which is within the required range of 105 to 120 degrees Fahrenheit. All necessary documents were in place. LPA observed the following posted on the facility wall: Facility license, sketch, See Something Say Something poster, Ombudsman poster, Theft and Loss Policy, Resident Bill of Rights, Rights of Resident/Family Councils.

The facility submitted a LIC 808 mitigation plan, which was approved. The facility has central entry point and has implemented screening and sign in procedures at the front door area. The facility conducts routine symptom screening for employees, residents, and visitors.

SUPERVISOR'S NAME: Liza King	TELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Kesha Lewis	TELEPHONE: (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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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
	VISIT DATE: 08/14/2023

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LPA observed the facility to have hand washing stations, COVID - 19 informational signage, and social distancing signs posted throughout the facility, on the front door, and outside. The facility has a designated infection control lead individual. The facility is able to designate and dedicated a COVID -19 room/bathroom if needed. Common touch surfaces are cleaned after each use. LPA observed the facility to have adequate food supply of 7 days non-perishables and 2 days perishables in place. Resident rooms were sanitary and had the required furniture and furnishings.

LPA observed, fire extinguishers inspected on 03/2023 and current, smoke and carbon monoxide detectors, central heating and air in the facility. The first aid kit was found in compliance containing at least the following: a current edition of a first aid manual approved by the American Red Cross, the American Medical Association or a state or federal health agency, sterile first aid dressings, bandages or roller bandages, adhesive tape, scissors, tweezers, thermometers, and Antiseptic solution.

LPA reviewed fifteen (15) staff files. All staff is fingerprint cleared and associated to the facility and staff have current First Aid or CPR certifications on file. Facility is conducting initial and continuing training as required.

LPA reviewed eighteen (18) resident facility files six (6) files from memory care and twelve (12) from assisted living, COVID-19 Plan, and survey binder. All necessary documents were in place.

Exit interview held and copy of report left at conclusion of visit.

SUPERVISOR'S NAME: Liza King	TELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Kesha Lewis	TELEPHONE: (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

LIC809 (FAS) - (06/04)

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