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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 392700475
Report Date: 04/18/2024
Date Signed: 04/18/2024 02:24:12 PM


Document Has Been Signed on 04/18/2024 02:24 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 SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827



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:
04/18/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
01:21 PM
MET WITH:Tha ChayTIME COMPLETED:
02:45 PM
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On 4/18/2024, Licensing Program Analyst Albert Johnson conducted an unannounced case management visit to the facility to follow up on an incident that occurred on 4/14/2024.

LPA reviewed special incident report dated 4/14/2024 stating R1 had an unwitnessed fall and as a result sustained a head injury requiring two staples.

R1 has a history of falls and the facility has taken precautions to minimize R1 from falling. R1 has a current service plan that addresses the fall risk with home health services to assist with balance and ambulation. R1 moved in with a walker and is legally blind.

During today's visit, LPA reviewed R1's file, medical records related to the fall and service plans dated 2/28/2023, 3/15/2023, 8/30/2023 and 3/19/2024. The facility appears to be exercising best practices with R1's service needs as it pertains to the fall risk mitigation.

The department has requested by the close of business on 4/19/2024, an updated LIC 500 with actual times that the Administrator is on-site.

Exit interview was conducted.
SUPERVISOR'S NAME: Lisa RiosTELEPHONE: (916) 969-9685
LICENSING EVALUATOR NAME: Albert JohnsonTELEPHONE: (916) 217-1390
LICENSING EVALUATOR SIGNATURE:
DATE: 04/18/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/18/2024
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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