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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 392701053
Report Date: 09/17/2024
Date Signed: 09/17/2024 12:11:24 PM


Document Has Been Signed on 09/17/2024 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
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: 0DATE:
09/17/2024
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:P. HillTIME COMPLETED:
11:45 AM
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On 9/17/2024, LPA was made aware that R1 passed away last night. The facility had one resident in care and since the passing of R1 the facility will no longer accept additional clients at this time. The Administrator will send in the death report and a letter to confirm that there will be no residents admitted until further notice.
SUPERVISOR'S NAME: Lisa RiosTELEPHONE: (916) 969-9685
LICENSING EVALUATOR NAME: Albert JohnsonTELEPHONE: (916) 217-1390
LICENSING EVALUATOR SIGNATURE:
DATE: 09/12/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/12/2024
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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