<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 455002559
Report Date: 08/21/2024
Date Signed: 08/21/2024 12:26:17 PM

Document Has Been Signed on 08/21/2024 12:26 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 NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME:OAK MESA HOMEFACILITY NUMBER:
455002559
ADMINISTRATOR/
DIRECTOR:		WILLIS, STEPHENFACILITY TYPE:
735
ADDRESS:1870 OAK MESATELEPHONE:
(530) 215-3973
CITY:REDDINGSTATE: CAZIP CODE:
96003
CAPACITY: 6CENSUS: 5DATE:
08/21/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:30 AM
MET WITH:Direct Care Staff, Tavarius Simmons
Administrator, Stephen Willis		TIME VISIT/
INSPECTION COMPLETED:
12:30 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 August 21, 2024 at approximately 11:30 AM, Licensing Program Analyst (LPA), Farhaan Sarangi arrived unannounced for the purpose of conducting a Case Management-Deficiencies inspection. Upon arrival, LPA was greeted at the door by, Direct Care Staff, Tavarius Simmons, and was granted access into the facility. Administrator arrived 15 minutes later.

On July 28, 2024, the facility reported to Community Care Licensing Division (CCLD) regarding three clients not receiving the medication. The Incident Report summarizes that at 03:00 PM medications were not passed on July 28, 2024 (See LIC 809D) for three clients in care. Administrator disclosed that the facility followed-up with the Nursing Consultant of the missed medications. LPA educated the Administrator regarding the importance of advising the Primary Care Physicians moving forward as outlined in Reporting Requirements.

On August 16, 2024, the facility reported to Community Care Licensing Division (CCLD) that a client left the facility on August 16, 2024 at 06:30 AM. However, Administrator disclosed that staff was shadowing the client until the Administrator took over. Client was never left unassisted and had staff members shadowing. LPA advised that the incident report reflects a different set of events. Administrator disclosed that there was an error on the Incident Report regarding the client eloping and that moving forward the incident reports will be articulated in a more clear and concise manner. LPA educated the Administrator about Reporting Requirements as well (See LIC 9102-Technical Advisory).

Deficiencies cited from the California Code of Regulations, Title 22, Division 6, Chapter 1 of California Regulation. Appeal rights were provided. Failure to correct the deficiency and/or repeat deficiencies within a 12-month period may result in civil penalties. Exit interview was conducted, and a copy of this signed report along with appeal rights were given to the Administrator.
SUPERVISORS NAME: Lauren Crocker
LICENSING EVALUATOR NAME: Farhaan Sarangi
LICENSING EVALUATOR SIGNATURE: DATE: 08/21/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/21/2024
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 2
Document Has Been Signed on 08/21/2024 12:26 PM - It Cannot Be Edited


Created By: Farhaan Sarangi On 08/21/2024 at 12:15 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
, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: OAK MESA HOME
FACILITY NUMBER: 455002559

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/21/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
08/22/2024
Section Cited
CCR
80075(b)

1
2
3
4
5
6
7
80075(b):
Clients shall be assisted as needed with self-administration of prescription and nonprescription medications.

This requirement was not met as evidenced by
1
2
3
4
5
6
7
Licensee/Administrator shall conduct staff training with ALL staff who dispense medication. In addition, Licensee shall furnish to CCL a LIC 9098 understanding of the regulation, a statement on how future compliance will be met and staff training.
8
9
10
11
12
13
14
Based on a review of an incident report that was forwarded to Community Care Licensing Regional Office (RO), the incident report reflects that 3 clients missed their 3:00 PM medications which presents an immeidate health, safety and personal rights risk to the clients in care.
8
9
10
11
12
13
14
POC Due Date: August 26, 2024

1
2
3
4
5
6
7
1
2
3
4
5
6
7

1
2
3
4
5
6
7
1
2
3
4
5
6
7
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:Lauren Crocker
LICENSING EVALUATOR NAME:Farhaan Sarangi
LICENSING EVALUATOR SIGNATURE:
DATE: 08/21/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/21/2024


LIC809 (FAS) - (06/04)
Page: 2 of 2