392701053-9-8-2021-27-AS-MBIR-C6NST4-20210908140856

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 392701053
Report Date: 09/08/2021
Date Signed: 09/08/2021 02:09:04 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:	OXFORD MANOR		FACILITY NUMBER:	392701053
ADMINISTRATOR:	HILL, SIMILY		FACILITY TYPE:	740
ADDRESS:	2313 OXFORD CIRCLE		TELEPHONE:	(415) 756-3652
CITY:	STOCKTON	STATE: CA	ZIP CODE:	95204
CAPACITY:	6	CENSUS: 0	DATE:	09/08/2021
TYPE OF VISIT:	Prelicensing	UNANNOUNCED	TIME BEGAN:	12:15 PM
MET WITH:	Penya Hill		TIME COMPLETED:	02:11 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 9/8/21 at 11:49am, Licensing Program Analyst (LPA) Michael Bilger conducted an announced pre-licensing visit to this facility. LPA was met by the Applicant, Penya Hill. 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 including signage, PPE storage and 30-day supply. Isolation rooms designated. LPA observed no obstruction of emergency exits. Exit signs in place as appropriate. Fire extinguisher in place at kitchen entry way and fully charged. Facility map indicating emergency exits posted in appropriate locations. Complaint poster and Ombudsman Poster observed. Kitchen area was toured. Cabinets and drawers were opened and reviewed by this LPA along with the Applicant. All sharps objects and toxins are secured and locked. 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 the hallway, was toured. 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 at 111.7* F which is within the allowed range of 105-120 degrees. Facility temperature was 79*F. 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. A tour of the exterior grounds was conducted. {Cont. on 809C}

SUPERVISOR'S NAME: Liza King	TELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Michael Bilger	TELEPHONE: 916-862-4722
LICENSING EVALUATOR SIGNATURE:	DATE: 09/08/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/08/2021

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: OXFORD MANOR	FACILITY NUMBER: 392701053
	VISIT DATE: 09/08/2021

NARRATIVE

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A review of the facility perimeter fence, side gates, and walkways were observed to be maintained in compliance at this time. Wheelchair ramps are in place at entry way and exit areas to the backyard.
This facility has been found to be in compliance at this time.
There were no deficiencies observed during today's Pre-licensing visit. Component III completed with applicant during visit. COVID-19 Mitigation plan has been received and approved.

Exit Interview conducted with Penya Hill. A copy of this report was left with the Applicant

SUPERVISOR'S NAME: Liza King	TELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Michael Bilger	TELEPHONE: 916-862-4722
LICENSING EVALUATOR SIGNATURE:	DATE: 09/08/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/08/2021

LIC809 (FAS) - (06/04)

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