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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 392700475
Report Date: 09/24/2024
Date Signed: 09/25/2024 08:28:06 AM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
This is an official report of an unannounced visit/investigation of a complaint received in our office on
06/20/2024 and conducted by Evaluator Albert Johnson
PUBLIC
COMPLAINT CONTROL NUMBER: 27-AS-20240620163357
FACILITY NAME:OAKS AT INGLEWOOD ASSISTED LIVING, THEFACILITY NUMBER:
392700475
ADMINISTRATOR:BRITTANY ANDREWSFACILITY TYPE:
740
ADDRESS:6725 INGLEWOOD AVETELEPHONE:
(209) 957-6257
CITY:STOCKTONSTATE: CAZIP CODE:
95207
CAPACITY:86CENSUS: 73DATE:
09/24/2024
UNANNOUNCEDTIME BEGAN:
01:04 PM
MET WITH:Tha ChayTIME COMPLETED:
03:05 PM
ALLEGATION(S):
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Facility staff are not properly cleaning facility kitchen
INVESTIGATION FINDINGS:
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Based on observation on 6/21/2024, 8/22/2024, and records reviewed the facility is not in compliance with the regulatory requirement to maintain a clean and sanitary kitchen with storage of food, expired food, unlabeled food, bread storage area not clean and open containers observed.

Based on staffing for the kitchen the facility is required to have consultation services for food services. The facility is out of compliance with this requirement. The last quarterly visit was on 8/30/2023, during the visit on 8/30/2023 the consultant identified several action items, including repeat problems and sanitation hazardous.

The facility is actively looking for a Dietitians to conduct the quarterly visits to assist the facility in coming back into compliance with this requirement.
(Advisory Given)
Substantiated
Estimated Days of Completion: 0
SUPERVISOR'S NAME: Lisa RiosTELEPHONE: (916) 969-9685
LICENSING EVALUATOR NAME: Albert JohnsonTELEPHONE: (916) 217-1390
LICENSING EVALUATOR SIGNATURE:

DATE: 09/24/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/24/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 3
Control Number 27-AS-20240620163357
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: OAKS AT INGLEWOOD ASSISTED LIVING, THE
FACILITY NUMBER: 392700475
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/24/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/10/2024
Section Cited
CCR
87555(b)(9)
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b) The following food service requirements shall apply:
(9) Procedures which protect the safety, acceptability and nutritive values of food shall be observed in food storage, preparation and service. This requirement is not met as evidenced by observation and records reviewed.
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The facility will hire a Consultant to assisted the facility as it relates to compliance with food safety and maintenance of hazardous concerns identified in the report dated 8/30/2023.
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observation on 6/21/2024, 8/22/2024, and records reviewed the facility is not in compliance with the regulatory requirement to maintain a clean and sanitary kitchen with storage of food, expired food, unlabeled food, bread storage area not clean and open containers.
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The consultant will be hired by POC date 10/10/24.

An advisory was given for consultant's visits which should be happening quarterly.
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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: Lisa RiosTELEPHONE: (916) 969-9685
LICENSING EVALUATOR NAME: Albert JohnsonTELEPHONE: (916) 217-1390
LICENSING EVALUATOR SIGNATURE:

DATE: 09/24/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/24/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 3
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
This is an official report of an unannounced visit/investigation of a complaint received in our office on
06/20/2024 and conducted by Evaluator Albert Johnson
PUBLIC
COMPLAINT CONTROL NUMBER: 27-AS-20240620163357

FACILITY NAME:OAKS AT INGLEWOOD ASSISTED LIVING, THEFACILITY NUMBER:
392700475
ADMINISTRATOR:BRITTANY ANDREWSFACILITY TYPE:
740
ADDRESS:6725 INGLEWOOD AVETELEPHONE:
(209) 957-6257
CITY:STOCKTONSTATE: CAZIP CODE:
95207
CAPACITY:86CENSUS: 73DATE:
09/24/2024
UNANNOUNCEDTIME BEGAN:
01:04 PM
MET WITH:Tha ChayTIME COMPLETED:
03:05 PM
ALLEGATION(S):
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Facility staff are not properly addressing pest infestation in facility
INVESTIGATION FINDINGS:
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Based on observation and records reviewed, it was determined that although pest were reportedly observed on the outside of facility they were not observed inside of facility. Additionally, record review revealed an insect crawling on the floor which was undetermined to be that of facility’s.

A pest control service agreement was reviewed and confirmed that on-going pest control service in place for facility. As a result, there is not a preponderance of evidence to conclude that facility has had an infestation of insects, therefore this allegation is UNSUBSTANTIATED.

Exit interview conducted.
Unsubstantiated
Estimated Days of Completion: 0
SUPERVISOR'S NAME: Lisa RiosTELEPHONE: (916) 969-9685
LICENSING EVALUATOR NAME: Albert JohnsonTELEPHONE: (916) 217-1390
LICENSING EVALUATOR SIGNATURE:

DATE: 09/24/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/24/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 3 of 3