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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 392701053
Report Date: 08/16/2023
Date Signed: 08/16/2023 03:03:11 PM


Document Has Been Signed on 08/16/2023 03:03 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:OXFORD MANORFACILITY NUMBER:
392701053
ADMINISTRATOR:HILL, PENYAFACILITY TYPE:
740
ADDRESS:2313 OXFORD CIRCLETELEPHONE:
(415) 756-3652
CITY:STOCKTONSTATE: CAZIP CODE:
95204
CAPACITY:6CENSUS: 3DATE:
08/16/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:15 AM
MET WITH:Penya HillTIME COMPLETED:
03:00 PM
NARRATIVE
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On 8/16/2023 at 10:15am, Licensing Program Analysts (LPAs) Michael Bilger and Arvin Villanueva arrived at this facility unannounced to conduct a required annual inspection visit. LPAs met with Administrator, Penya Hll and explained the purpose of the visit.

LPAs toured the facility including but not limited to bedrooms, bathrooms, kitchen, common area and backyard. The facility consists of 3 resident bedrooms and 1 staff room. LPA observed lighting in all rooms are adequate for the comfort and safety of the residents. A comfortable temperature is maintained at 70 degrees Fahrenheit. The hot water temperature in the residents’ shared bathroom was measured between 105 and 120 degrees Fahrenheit. Smoke alarms and carbon monoxide alarms were tested successfully. Residents’ bathrooms are equipped with grab bar and non-skid mats.

Facility has an emergency food supply. There is a minimum of 7-day supply of nonperishable and 2-day of perishable foods. All toxins and other dangerous items including sharp objects were locked and inaccessible. Medication storage area was observed to be locked and inaccessible. First aid kit was observed to have adequate supplies and accessible to staff.

All staff noted on LIC 500 contained criminal background clearances. LPA completed 1 staff interview. Facility’s liability insurance is current and update to date per regulatory requirements. Facility does not contain any bodies of water. LPA observed personal rights poster. Facility has appropriate internet access available for resident use. LPA reviewed facility’s disaster plan to ensure regulatory compliance.Updated copy of LIC 308 and LIC 500, and current liability insurance were provided to LPAs during the visit. Based on observation, interview, and record review, LPAs observed 2 of 3 residents maintaining a bedridden status without appropriate fire clearance. LPAs reviewed 3 residents charts and 2 staff charts. Staffing charts did not contain updated regulatory required training upon review.
Per California Code of Regulations, Title 22, deficiencies were observed during this visit. Exit interview was held and a report was given to Penya Hill.
SUPERVISOR'S NAME: Stephen RichardsonTELEPHONE: (916) -26-4700
LICENSING EVALUATOR NAME: Arvin VillanuevaTELEPHONE: 916-558-2130
LICENSING EVALUATOR SIGNATURE:
DATE: 08/16/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/16/2023
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


Document Has Been Signed on 08/16/2023 03:03 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
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827


FACILITY NAME: OXFORD MANOR
FACILITY NUMBER: 392701053

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/16/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87202(a)(2)
Fire Clearance
(a) All facilities shall maintain a fire clearance approved by the city, county, or city and county fire department or district providing fire protection services, or the State Fire Marshal. Prior to accepting or retaining any of the following types of persons, the applicant or licensee shall notify the licensing agency and obtain an appropriate fire clearance approved by the city, county, or city and county fire department or district providing fire protection services, or the State Fire Marshal: (2) Bedridden persons

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on facility observation, interviews and record reviews, the licensee did not comply with the section cited above in 2 out of 3 residents which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 08/17/2023
Plan of Correction
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Licensee to read regulation 87202(a)(2) and submit a signed declaration of understanding to LPA by POC due date.
Licensee to obtain fire clearance. Licensee has already submitted preliminary documents for the fire clearance to LPAs during the visit. Licensee to read and submit a signed declaration of understainding Section 87606 Care of Bedridden Residents and submit an updated plan of operations per regulations.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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: Stephen RichardsonTELEPHONE: (916) -26-4700
LICENSING EVALUATOR NAME: Arvin VillanuevaTELEPHONE: 916-558-2130
LICENSING EVALUATOR SIGNATURE:
DATE: 08/16/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/16/2023
LIC809 (FAS) - (06/04)
Page: 2 of 3


Document Has Been Signed on 08/16/2023 03:03 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
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827


FACILITY NAME: OXFORD MANOR
FACILITY NUMBER: 392701053

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/16/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.625(b)(1)
Other Provisions
(1) The department shall adopt regulations to require staff members of residential care facilities for the elderly who assist residents with personal activities of daily living to receive appropriate training. This training shall consist of 40 hours of training. A staff member shall complete 20 hours, including six hours specific to dementia care, as required by subdivision (a) of Section 1569.626 and four hours specific to postural supports, restricted health conditions, and hospice care, as required by subdivision (a) of Section 1569.696, before working independently with residents. The remaining 20 hours shall include six hours specific to dementia care and shall be completed within the first four weeks of employment. The training coursework may utilize various methods of instruction, including, but not limited to, lectures, instructional videos, and interactive online courses. The additional 16 hours shall be hands-on training.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and record reviews, the licensee did not comply with the section cited above in 1 out of 2 staff which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/31/2023
Plan of Correction
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Licensee to submit completed required staff training specified in the regulation HSC 1569.625(b)(1) by POC due date.
Licensee to read regulation HSC 1569.625(b)(1) and submit a signed declaration of understanding to LPA by POC due date.

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: Stephen RichardsonTELEPHONE: (916) -26-4700
LICENSING EVALUATOR NAME: Arvin VillanuevaTELEPHONE: 916-558-2130
LICENSING EVALUATOR SIGNATURE:
DATE: 08/16/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/16/2023
LIC809 (FAS) - (06/04)
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