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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 392701053
Report Date: 08/24/2021
Date Signed: 08/24/2021 12:11:50 PM

Document Has Been Signed on 08/24/2021 12:11 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:OXFORD MANORFACILITY NUMBER:
392701053
ADMINISTRATOR:HILL, SIMILYFACILITY TYPE:
740
ADDRESS:2313 OXFORD CIRCLETELEPHONE:
(415) 756-3652
CITY:STOCKTONSTATE: CAZIP CODE:
95204
CAPACITY: 6CENSUS: 0DATE:
08/24/2021
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
09:44 AM
MET WITH:Penya HillTIME COMPLETED:
12:20 PM
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Licensing Program Analyst (LPA) Michael Bilger conducted an announced pre-licensing visit to this facility on 08/24/2021 at 9:44am and was met by the Applicant, Penya Hill. A Brief interview was conducted with the Applicant.
It was learned that this facility will be licensed to serve up to 6 non-ambulatory clients. There were no clients present during today's pre-licensing visit. Tour of the facility was conducted.
Dining area, living area, and all other areas intended for resident use were toured and observed to be furnished and maintained in compliance at this time. COVID Precautions in place. Isolation rooms designated. LPA observed no obstruction of emergency exits. Fire extinguisher in place in kitchen and fully charged. Complaint poster observed.
Kitchen area was toured. Cabinets and drawers were opened and reviewed by this LPA along with the Applicant.
Food supply for 2-day perishable and 7-day nonperishable quantities were reviewed to make sure that this facility was in compliance at this time.
Medication cabinet located in hallway was observed. First aid kit was observed to be present and contained all required components at this time.
A tour of the resident bedrooms was conducted. Furnishings and furniture intended for use by the clients were observed to be sufficient and able to meet the needs of the clients at this time.
A tour of the resident bathrooms was conducted. Hot water temperatures were taken and measured within the allowed range of 105-120 degrees.
Linen closet, located in the hallway, was observed to contain a sufficient supply of towels and linens able to meet the needs of the residents at this time. LPA received COVID mitigation plan during visit.

{Cont. on 809C}
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Michael Bilger
LICENSING EVALUATOR SIGNATURE: DATE: 08/24/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/24/2021
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 3
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: OXFORD MANOR
FACILITY NUMBER: 392701053
VISIT DATE: 08/24/2021
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A tour of the exterior grounds was conducted. A review of the facility perimeter fence, side gates, and walkways were observed.
This facility has been found to require the following in place before considered for licensure:

1. Ramp to be installed at outside exit from main sliding door and resident room #3 sliding door

2. Facility flooring to be free of dirt and clutter

4. Facility sketches to be posted

5. Ombudsman poster to be posted

6. COVID-19 signage to be posted

Exit Interview conducted with Penya Hill. A copy of this report was left with the Applicant
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Michael Bilger
LICENSING EVALUATOR SIGNATURE:

DATE: 08/24/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/24/2021
LIC809 (FAS) - (06/04)
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