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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 486803614
Report Date: 02/12/2021
Date Signed: 02/16/2021 05:29:24 PM



STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928
This is an official report of an unannounced visit/investigation of a complaint received in our office on
03/23/2020 and conducted by Evaluator Araceli Canela
PUBLIC
COMPLAINT CONTROL NUMBER: 21-AS-20200323144313
FACILITY NAME:OAKWOOD MEMORY & SENIOR CAREFACILITY NUMBER:
486803614
ADMINISTRATOR:ESTHER ZELEDONFACILITY TYPE:
740
ADDRESS:1025 OAKWOOD AVENUETELEPHONE:
(707) 643-0473
CITY:VALLEJOSTATE: CAZIP CODE:
94591
CAPACITY:30CENSUS: 10DATE:
02/12/2021
UNANNOUNCEDTIME BEGAN:
02:06 PM
MET WITH:Teresa iLagan "TJ"TIME COMPLETED:
03:07 PM
ALLEGATION(S):
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Staff intimidated resident and threatened with eviction
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) A. Canela contacted Teresa iLagan "TJ", care staff/manager at Oakwood Memory & Senior Care Facility by telephone on 2/12/2021 for the purpose of delivering findings on a complaint investigation 21-AS-20200323144313. Due to COVID – 19 precautions a facility visit is not able to be conducted at this time.

LPA received statements and gathered records. It was alleged facility staff intimidated resident and threatened with eviction. Investigation revealed resident R1 used their private cell phone to call 911 due to a stomach ache. It was corroborated to LPA by EMT personnel, that facility staff threatened R1, that if R1 went to the hospital R1 would not be allowed to return to the facility. Facility staff S1 explained, due to the recent Covid-19 pandemic they felt R1 could be exposed to the virus and felt R1 did not need to go to the Hospital, but could be assessed with a phone call to R1's physician.

Continue report see LIC9099-C
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Bethany MoellersTELEPHONE: (707) 588-5026
LICENSING EVALUATOR NAME: Araceli CanelaTELEPHONE: (707) 588-5041
LICENSING EVALUATOR SIGNATURE:

DATE: 02/12/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/12/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 3
Control Number 21-AS-20200323144313
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928
FACILITY NAME: OAKWOOD MEMORY & SENIOR CARE
FACILITY NUMBER: 486803614
VISIT DATE: 02/12/2021
NARRATIVE
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Based on the above information the preponderance of evidence standard has been met, therefore the above allegation for Staff intimidated resident and threatened with eviction, is found to be SUBSTANTIATED. California Code of Regulations, (Title 22, Division 6, Chapter 8), is being cited on the attached LIC 9099D. Appeal Rights were provided and signature on this report acknowledges receipt.
SUPERVISOR'S NAME: Bethany MoellersTELEPHONE: (707) 588-5026
LICENSING EVALUATOR NAME: Araceli CanelaTELEPHONE: (707) 588-5041
LICENSING EVALUATOR SIGNATURE:

DATE: 02/12/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/12/2021
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 21-AS-20200323144313
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928

FACILITY NAME: OAKWOOD MEMORY & SENIOR CARE
FACILITY NUMBER: 486803614
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/12/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
02/13/2021
Section Cited
CCR
87468.1(a)(3)
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87468.1(a)(3) Personal Rights of Residents in All Facilities. (a) Residents in all residential care facilities for the elderly shall have all of the following personal rights. (3) To be free from punishment, humiliation, intimidation, abuse, or other actions of a punitive nature, such as withholding residents’ money or
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Licensee to send in written plan that they understand regulation 87468.1 regarding residents personal rights. Plan of staff training date and proof of staff training sent to CCL after completion
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interfering with daily living functions such as eating, sleeping, or elimination. This requirement was not met as evidenced by: Based on statements received from outside parties and facility staff S1. R1 was threatened by staff that R1 would not be allowed to return to facility if she went to the Emergency department. This is an immediate health and safety risk to residents in care.
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1st POC plan, due date by 2/13/2021-proof of completion of training due by 2/23/2021
Attention: LPA A. Canela
Fax(707)588-5080
email araceli.canela@dss.ca.gov
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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: Bethany MoellersTELEPHONE: (707) 588-5026
LICENSING EVALUATOR NAME: Araceli CanelaTELEPHONE: (707) 588-5041
LICENSING EVALUATOR SIGNATURE:

DATE: 02/12/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/12/2021
LIC9099 (FAS) - (06/04)
Page: 3 of 3