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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 392700475
Report Date: 01/31/2023
Date Signed: 01/31/2023 04:41:18 PM


COMPREHENSIVE INSPECTION

Document Has Been Signed on 01/31/2023 04:41 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
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833



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: 77DATE:
01/31/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:00 PM
MET WITH:Brittany AndrewsTIME COMPLETED:
04:45 PM
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On 1/31/23 Licensing Program Analyst (LPA) Maja Jensen arrived at facility unannounced to conduct a required one year annual visit. LPA Jensen met with Executive Director Brittany Andrews and explained the purpose of today's visit.

The facility is a two story structure with a capacity to serve 86 resident and a current census of 77. The grounds were observed to be maintained and clear of obstruction and debris. There is pond on the premises that was observed to be gated and locked. There is sufficient outdoor furniture for the residents to participate in outdoor activities and pergolas for shade.

The interior of the facility was toured including common areas, dining room, kitchen, life enrichment room, guest reception areas, resident apartments, laundry room and medication room. The facility was observed to be sanitary and free of odor. LPA Jensen observed and tested carbon monoxide detectors and determined them to be in good working order. LPA Jensen observed the fire extinguishers were last serviced in November of 2022 and are in compliance. The Ansul System was observed to be last serviced in November of 2022 and is in compliance. LPA Jensen observed the facility to maintain a first aid kit that was complete with scissors, tweezers, a thermometer, various wound dressings and 1st aid manual. The facility has stair wells that are quipped with evacuation chairs. The temperature in the common areas of the facility was observed to be set 72 degrees which falls within the required regulatory range of 68-85 degrees. The facility is currently undergoing window replacement on the upper level. An upper level window in the main hall was removed this morning and is being replaced with an expected completion same day. The work area was sectioned off with caution tape.

Continued on LIC 809C....
SUPERVISOR'S NAME: Liza KingTELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Maja JensenTELEPHONE: 916-639-5584
LICENSING EVALUATOR SIGNATURE:
DATE: 01/31/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/31/2023
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
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: 01/31/2023
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The resident bedrooms were observed to be adequately furnished and contained dressers, night stands, lamps. The temperature in resident apartments was measured at 120 degrees which falls within the required regulatory range of 105-120 degrees.

The Medication Administration Records are electronic and PRN effectiveness is documented. The medication room is locked and inaccessible to residents in care. The narcotics were observed to be double locked. LPA Jensen verified the narcotic count with Medication Technician 1 (MT1) and determined the record keeping to be accurate.

3 resident files were reviewed. 3 of 3 resident files lacked an LIC 621. The resident file for resident 1 (R1) also lacked a current resident evaluation. The resident evaluation for R1 was last conducted on 3/17/21. 2 of 3 resident files reviewed have physician orders to retain and manage their own medication.

The kitchen was observed to have in excess of 2 days of perishable food and 7 days of non-perishable food. The menu was posted outside of the dining hall and is also delivered to individual suites. The menu accurately reflected was observed to be served during lunch service.

LPA Jensen requested a current LIC 500 and a current copy of liability insurance be emailed to maja.jensen@dss.ca.gov by 2/2/23.

Deficiencies are being cited on this day from the California Code of Regulations (CCR) Title 22, Division 6. Failure to correct deficiencies may result in the assessment of civil penalties.

An exit interview was conducted and a copy of this report and appeal rights were provided.
SUPERVISOR'S NAME: Liza KingTELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Maja JensenTELEPHONE: 916-639-5584
LICENSING EVALUATOR SIGNATURE:

DATE: 01/31/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/31/2023
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 01/31/2023 04:41 PM - It Cannot Be Edited

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

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/31/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
02/28/2023
Section Cited

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87218 Theft and Loss

(a) The licensee shall ensure an adequate theft and loss program as specified in Health and Safety Code Section 1569.153.

(1) The initial personal property inventory shall be completed by the licensee, and the resident, or the resident’s representative. This requirement was not met as evidenced by:
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The Licensee agrees to submit a plan for compliance to maja.jensen@dss.ca.gov by plan of correction due date.
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Based on LPA Jensen's observation of 3 of 3 resident files lacking record of any inventory conucted upon admission. This poses a potential risk to the health, safety and personal rights of residnets in care.
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Type B
02/28/2023
Section Cited

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Resident Participation in Decisionmaking

The licensee shall arrange a meeting with the resident and appropriate individuals identified in Section 87467(a)(1) to review and revise the written record as specified, when there is a significant change in the resident’s condition, or once every 12 months, whichever occurs first. Significant changes shall include, but not be limited to occurrences specified in Section 87463, Reappraisals. This requirement was not met as evidenced by:
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The Licensee agrees to update resident appraisals by the Plan of Correction due date and to send an attestation that this has been complated by Plan of Correction due date. The attestation will be emailed to maja.jensen@dss.ca.gov.
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This requirement was not met as evidenced by the resident file for R1 not having an updated appraisal since 3/17/21. This poses a potential risk to the health, safety and personal rights of residents in care.
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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: Liza KingTELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Maja JensenTELEPHONE: 916-639-5584
LICENSING EVALUATOR SIGNATURE:
DATE: 01/31/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/31/2023
LIC809 (FAS) - (06/04)
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