486803614-4-14-2023-21-AS-CMAZ-CR3MVE-20230420095637

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 486803614
Report Date: 04/14/2023
Date Signed: 04/14/2023 12:37:32 PM

Substantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

This is an official report of an unannounced visit/investigation of a complaint received in our office on
03/27/2023 and conducted by Evaluator David Leibert

COMPLAINT CONTROL NUMBER: 21-AS-20230327160637

FACILITY NAME:	OAKWOOD MEMORY & SENIOR CARE		FACILITY NUMBER:	486803614
ADMINISTRATOR:	MAHAWAR, RASHMIKA		FACILITY TYPE:	740
ADDRESS:	1025 OAKWOOD AVENUE		TELEPHONE:	(707) 643-0473
CITY:	VALLEJO	STATE: CA	ZIP CODE:	94591
CAPACITY:	30	CENSUS: 19	DATE:	04/14/2023
		UNANNOUNCED	TIME BEGAN:	11:15 AM
MET WITH:	TJ Ilagan		TIME COMPLETED:	01:00 PM

ALLEGATION(S):

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Facility staff refused to take patient back after hospitalization.
Resident is being illegally evicted from the facility.

INVESTIGATION FINDINGS:

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Licensing Program Analyst Leibert arrived unannounced for the purpose of delivering findings on this complaint. LPA met with TJ Ilagan and discussed the complaint. During the course of this investigation, this Department has reviewed documents and taken witness statements. The following determinations are made: R1 was admitted to a medical facility on 03/25/2025; On or about 03/27/2023, R1 was medically cleared for release and R1's care facility was notified; On 03/28/2023, in conversation with medical social worker, W1, care facility staff indicated refusal to accept R1 back into the care facility and indicated that R1 was evicted from the care facility; R1 remained in the medical facility until 04/04/2023, at which time R1 was placed in an alternate care facility; Care facility has failed to provide proof of filing an unlawful detainer/court order in compliance with H&S 1569.683(a)(4). Based upon statements and documents, the preponderance of evidence standard has been met. Therefore, the allegations are SUBSTANTIATED. The following deficiencies were observed (see LIC 9099D) and cited from the California Code of Regulations, Title 22, Division 6 of California Regulation. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties. Exit interview conducted and appeal of rights provided.

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Carla Martinez	TELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: David Leibert	TELEPHONE: (707) 588-5086
LICENSING EVALUATOR SIGNATURE:	DATE: 04/14/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/14/2023

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 21-AS-20230327160637

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: OAKWOOD MEMORY & SENIOR CARE	FACILITY NUMBER: 486803614
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 04/14/2023

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Deficiency Dismissed Type A 04/21/2023 Section Cited CCR 87464(f)(6)	1 2 3 4 5 6 7	87464(f)(6) Basic Services. (Basic services shall at a minimum include) Arrangements to meet health needs, including arranging transportation, as specified in Section 87465, Incidental Medical and Dental Care Services. ****Based upon statements, this requirement not met as evidenced by:	1 2 3 4 5 6 7	Administration will review 87464 and 87224 and submit a signed and dated declaration to CCL that outlines how facility will comply with the requirement of the regulations going forward. Declaration to be submitted by POC date in order to clear the deficiency.
	8 9 10 11 12 13 14	Facility refused to return R1 to facility when R1 was medically cleared to return. This posed an immediate risk to R1’s health and welfare.	8 9 10 11 12 13 14
Deficiency Dismissed Type B 04/14/2023 Section Cited CCR 87224(d)(1))D)	1 2 3 4 5 6 7	87224(d)(1)(D) Eviction procedures. …In order to evict a resident who remains in the facility after the effective date of the eviction, the residential care facility for the elderly must file an unlawful detainer action in superior court….***Based on statements and lack of documents, this requirement not met as evidenced by: Facility refused	1 2 3 4 5 6 7	Administration will review 87464 and 87224 and submit a signed and dated declaration to CCL that outlines how facility will comply with the requirement of the regulations going forward. Declaration to be submitted by POC date in order to clear the deficiency.
	8 9 10 11 12 13 14	R1’s return to facility without fully complying with eviction procedures. This posed a potential risk to R1’s personal rights.	8 9 10 11 12 13 14

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: Carla Martinez	TELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: David Leibert	TELEPHONE: (707) 588-5086
LICENSING EVALUATOR SIGNATURE:	DATE: 04/14/2023

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/14/2023

LIC9099 (FAS) - (06/04)

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