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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415600989
Report Date: 02/10/2025
Date Signed: 02/10/2025 06:52:17 PM

Document Has Been Signed on 02/10/2025 06:52 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
SAN BRUNO RO, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
FACILITY NAME:OAKWOOD HOMEFACILITY NUMBER:
415600989
ADMINISTRATOR/
DIRECTOR:		MADONNA VALENCIAFACILITY TYPE:
734
ADDRESS:313 EAST OAKWOOD BLVDTELEPHONE:
(650) 995-7837
CITY:REDWOOD CITYSTATE: CAZIP CODE:
94061
CAPACITY: 4CENSUS: 4DATE:
02/10/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
03:15 PM
MET WITH:Madonna ValenciaTIME VISIT/
INSPECTION COMPLETED:
07:00 PM
NARRATIVE
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LPA Audrey Jeung toured facility and grounds, including detached garage. All passageways are unobstructed and there are no accessible bodies of water or safety hazards observed. Medications and sharps are stored appropriately and inaccessible to clients. Hot water temperature is tested at 116 degrees in main shower/bathroom. Food supply--consisting of liquid formula for 3 clients and regular food for one--and first-aid kit are inspected, and hygiene items for general use are maintained, as well as PPE.
All residents have Hill-Rom hospital beds and all utilize full bed rails; facility maintains approved waiver for use of full bed rails.
Disaster drills are documented and are conducted regularly; the most recent one was done in December 2023. Client files are reviewed, including review of client's personal and incidental money log. Medications are recorded on Centrally Stored Medications Records. Criminal record clearances or exemptions for facility staff or other individuals who have client contact have been reviewed, including required staff records. Madonna Valencia and Claire Ascalon are certified ARF administrators (x 10/25 and 6/26) that oversee facility operations for this Adult Residential Facility for Persons with Special Health Care Needs. Facility employs LVNs and RNs around the clock to administer nutrition, hydration and medications; professional licenses for LVNs and RNs on premises are verified as current.
There is no staff room, as facility employs awake night staff.

The following updated forms are given to LPA today:
• LIC 500 Personnel Report
• LIC 309 Administrative Organization
• Proof of current surety bonding

Deficiency of the California Code of Regulations, Title 22 is cited on a following page. See also Technical Advisory notes--2 pages.
SUPERVISORS NAME: April Cowan
LICENSING EVALUATOR NAME: Audrey Jeung
LICENSING EVALUATOR SIGNATURE: DATE: 02/10/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/10/2025
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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Document Has Been Signed on 02/10/2025 06:52 PM - It Cannot Be Edited


Created By: Audrey Jeung On 02/10/2025 at 06:25 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066

FACILITY NAME: OAKWOOD HOME
FACILITY NUMBER: 415600989

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/10/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80019(e)
Criminal Record Clearance
(e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1522 shall prior to working, residing or volunteering in a licensed facility:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on review of staff records, the licensee did not comply with the section cited above in 1 out of 4 staff records reviewed, which poses an immediate health, safety or personal rights risk to persons in care.

- There is no proof that staff #1 maintains criminal record clearance. She has been employed since 1/2024, but had a leave of absence recently.
POC Due Date: 02/10/2025
Plan of Correction
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Proof of criminal record clearance and association to facility per Guardian was provided during LPA's presence.
Deficiency corrected and cleared
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:April Cowan
LICENSING EVALUATOR NAME:Audrey Jeung
LICENSING EVALUATOR SIGNATURE:
DATE: 02/10/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/10/2025


LIC809 (FAS) - (06/04)
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