392700475-11-9-2021-27-AS-ABOE-C8LRJ9-20211109120333

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 392700475
Report Date: 11/09/2021
Date Signed: 11/09/2021 12:03:48 PM

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:	OAKS AT INGLEWOOD ASSISTED LIVING, THE		FACILITY NUMBER:	392700475
ADMINISTRATOR:	WRIGHT, DIANE		FACILITY TYPE:	740
ADDRESS:	6725 INGLEWOOD AVE		TELEPHONE:	(209) 957-6257
CITY:	STOCKTON	STATE: CA	ZIP CODE:	95207
CAPACITY:	86	CENSUS: 69	DATE:	11/09/2021
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	10:20 AM
MET WITH:	Diane Wright		TIME COMPLETED:	12:15 PM

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	On 11/9/2021 at 10:20am Licensing Program Analyst (LPA) Ashley Boothe arrived unannounced to conduct a Required 1-year Annual inspection. LPA COVID screened upon entry. LPA met with Administrator and was allowed entry into the facility that is licensed to serve a total capacity of 86, today's census is 69. Eleven of eleven staff observed on site with criminal record clearance in Licensing Information System. LPA observed Administrator Certificate expires on 8/7/2023. LPA interacted with a random number of residents during this visit and observed residents engaged in activities. The physical plant was toured inside and outside to ensure the safety of the residents. LPA observed kitchen, dining room, storage areas, restrooms, apartments, and common living areas to be clean and in good repair. The temperature inside the facility was measured at 75F which is within the required range of 68F and 85F, or in areas of extreme heat the maximum shall be 30F less than the outside temperature. The hot water was measured at 108F within regulatory range of is not less than 105F and not more than 120*F. LPA observed the centrally stored medications, toxins and knives to be inaccessible to residents. LPA observed medications administered on today's date. The first aid kit was observed in compliance containing at least the following: a current edition of an approved first aid manual, sterile first aid dressings, bandages or roller bandages, adhesive tape, tweezers, scissors, thermometers, and Antiseptic solution. LPA observed food supplies of staple nonperishable foods for a minimum of one week and fresh perishable foods for a minimum of two days which shall be maintained on the premises at all times. LPA observed staff in kitchen with food handlers cards and chef food safe certified. Continued on 809 C.

SUPERVISOR'S NAME: Liza King	TELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Ashley Boothe	TELEPHONE: (916) 708-7751
LICENSING EVALUATOR SIGNATURE:	DATE: 11/09/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/09/2021

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
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

FACILITY NAME: OAKS AT INGLEWOOD ASSISTED LIVING, THE	FACILITY NUMBER: 392700475
	VISIT DATE: 11/09/2021

NARRATIVE

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Continued from 809.

LPA observed fire extinguisher last inspected on 10/6/2021, smoke and carbon monoxide detectors, central heating and air in the facility. LPA observed fire suppression system last annual inspection July 2021. LPA observed one of two elevators last annual inspection 10/31/2021 and Administrator stated inspection of other elevator, not in use, scheduled for tomorrow. Maintenance Director stated emergency binder in use for emergency preparedness and documenting staff training. LPA observed chair lifts in stairwells in four of five stairwells. Maintenance Director stated one will be ordered for stairwell and emergency evacuation procedures will be updated.

LPA observed COVID precautions signs posted, restrooms stocked with hand soap, hand washing signs, paper towels, and touchless covered trash cans. LPA observed 30 day supply of PPE stored is stored.

The facility has an approved Mitigation Plan.

Upon a file review the following items were discussed to be submitted to LPA by 11/20/2021:
Administrative Organization LIC309
Designation of Administrative Responsibility LIC308
Qualifications of Administrator
Personnel Report LIC500
Emergency Disaster Plan LIC610D

Per California Code of Regulations (CCRs) - Title 22, no deficiencies observed or cited. Exit interview held and a copy of report provided.

SUPERVISOR'S NAME: Liza King	TELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Ashley Boothe	TELEPHONE: (916) 708-7751
LICENSING EVALUATOR SIGNATURE:	DATE: 11/09/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/09/2021

LIC809 (FAS) - (06/04)

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