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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 392700475
Report Date: 05/08/2025
Date Signed: 05/08/2025 03:57:48 PM

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
05/08/2025 and conducted by Evaluator Albert Johnson
PUBLIC
COMPLAINT CONTROL NUMBER: 27-AS-20250508090354
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: 78DATE:
05/08/2025
UNANNOUNCEDTIME BEGAN:
01:02 PM
MET WITH:Yanet Rico -Solis
(Health and Wellness Director)		TIME COMPLETED:
04:00 PM
ALLEGATION(S):
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Staff are charging a resident for services not received
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Albert Johnson arrived at facility unannounced to open a complaint investigation into the above listed allegations.

Based on records reviewed and interviews conducted the facility is not following their approved plan of operation. The facility's plan of operation submitted to the department has been amended to include a new level of care description and fees. The facility has implemented this new level of care descriptions and fees without submitting to the licensing agency for approval prior to implementation.

Based on records reviewed and interviews conducted the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. California Code of regulations, Title 22 are being cited on the attached LIC 9099D. Exit interview conducted and a copy of this report was 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: 05/08/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/08/2025
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 2
Control Number 27-AS-20250508090354
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: 05/08/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
05/19/2025
Section Cited
CCR
87208(a)(1-3)
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(a) The licensee shall have and maintain a current, written definitive plan of operation for the facility. The licensee shall operate the facility in accordance with the terms specified in the plan of operation and may be cited for not doing so pursuant to Health and Safety Code section 1569.49. The plan and related materials shall be on file in the facility and shall be submitted to the licensing agency with the license application. Any significant changes in the plan of operation which would affect the services to residents shall be submitted to the licensing agency for approval. The plan and related materials shall contain the following:(1) Statement of purposes and program goals.
(2) A copy of the Admission Agreement, containing basic and optional services.(3) Statement of admission policies and procedures regarding acceptance of persons for services.
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Licensee will ensure an updated plan of operation be submitted to LPA by POC due date to include, but not be limited to:
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This requirement is not met as evidenced by information reviewed and interviews conducted.
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Amending the current admission agreement and care conference plan to include a new level of care description and fees. The new forms should be signed by all responsible party or individuals.
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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: 05/08/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/08/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 2