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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 392700475
Report Date: 06/17/2024
Date Signed: 06/18/2024 09:20:33 AM


Document Has Been Signed on 06/18/2024 09:20 AM - 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: 73DATE:
06/17/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Amber ArechigaTIME COMPLETED:
12:30 PM
NARRATIVE
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On 6/17/2024, Licensing Program Analyst (LPA) Albert Johnson conducted an unannounced Case Management visit today at the facility. LPA was following -up on an incident dated 6/11/2024 for a fall with a fracture.

During visit LPA Johnson reviewed records for R1, interviewed the Resident Services Coordinator about events related to R1's service needs. The records reviewed included transmittals to R1's primary care physician (PCP). The records indicated that R1 had an incident on 5/28/2024, R1 stated to staff that " I ran into a wall". R1 was complaining about left arm pain. R1 was given a PRN medication (Tramadol). R1's information was sent to the PCP on that same day 5/28/2024 and the PCP ordered the facility to get a X-ray of the left arm. On 6/4/2024, the facility received notification from the responsible party(RP) for the resident. The RP refused to follow PCP orders to have left arm X-rayed. (RP Stated "not necessary.")

On 6/11/2024, R1 had a fall, called 911 themselves, R1 was complaining about left arm pain, R1 was taken by AMR to the ER and was treated for a fracture of the hip.

Deficiencies were cited during this visit.

The Department will review the information and will return at a later date if a civil penalty is warranted.


Exit interview held.
SUPERVISOR'S NAME: Lisa RiosTELEPHONE: (916) 969-9685
LICENSING EVALUATOR NAME: Albert JohnsonTELEPHONE: (916) 217-1390
LICENSING EVALUATOR SIGNATURE:
DATE: 06/17/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/17/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2


Document Has Been Signed on 06/18/2024 09:20 AM - 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
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: 06/17/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
06/18/2024
Section Cited
CCR
87464(f)(6)

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87464 Basic Services (f) Basic services shall at a minimum include: (6) Arrangements to meet health needs, including arranging transportation, as specified in Section 87465, Incidental Medical and Dental Care Services. This requirement was not met as evidenced by
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Licensee to ensure all staff are up to date and are knowledgeable of the latest PINs and regulations.
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The facility not following the doctors orders and not taking R1 to have a X-ray on the left arm at the request of the PCP.
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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: 06/17/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/17/2024
LIC809 (FAS) - (06/04)
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