486803614-9-10-2024-21-AS-ACAA-D8YLJX-20240910084841

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 486803614
Report Date: 09/09/2024
Date Signed: 09/10/2024 08:49:42 AM

Document Has Been Signed on 09/10/2024 08:49 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT

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
ADMINISTRATOR:	MAHAWAR, RASHMIKA		FACILITY TYPE:	740
ADDRESS:	1025 OAKWOOD AVENUE		TELEPHONE:	(707) 643-0473
CITY:	VALLEJO	STATE: CA	ZIP CODE:	94591
CAPACITY:	30	CENSUS: 14	DATE:	09/09/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	12:05 PM
MET WITH:	Theresa Ilagan aka TJ, Facility Manager		TIME COMPLETED:	03:58 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	At approximately 12:05 PM, Licensing Program Analyst (LPA) Araceli Canela made an unannounced annual required 1 Year inspection of this licensed senior care facility. LPA met with facility manager, Theresa Ilagan aka TJ; Administrator, Rashmika "Rose" Mahawar was not available during the visit. LPA toured the building and grounds, Facility is not using the left wing and LPA observed 2 beds in the wide hallway that will need to be removed. This facility has two wings and at this time the facility is only using the right wing as there are only 14 residents living in the facility. Upon arrival the residents were waiting to have lunch and LPA observed the dining area closed and several tables that had a plate of food covered and a drink for the residents to come in and eat. LPA observed and felt the top of the cover and the food appeared to be cold. LPA checked with several residents that were able to communicate with LPA and they all expressed the food was cold, but they can ask to be re heated. LPA went over food requirements with cook and TJ and explained the food should be warm and the solution is not to reheat it because the food is being left there for several minutes. LPA toured the kitchen and observed the refrigerators and freezer need a little cleaning. LPA also observed that the dishes appear to be getting washed by hand and the unit that they have to do a disinfecting cycle was observed to have the rack filthy with dark dirt/stain. LPA requested TJ to show LPA how it worked and after a few minutes when the machine finished, LPA observed that the machine does not operate with Hot water and the dishes came out cold. LPA requested facility to get machine fixed so that it is operational and provide proof. All notices that are required to be posted have been posted and are in a highly visible area. LPA observed activity supplies for resident use. The amount of fresh and nonperishable foods is within regulation. Continued on LIC809-C...

SUPERVISOR'S NAME: Kimberley Mota	TELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Araceli Canela	TELEPHONE: (707) 588-5041
LICENSING EVALUATOR SIGNATURE:	DATE: 09/09/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/09/2024

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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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
	VISIT DATE: 09/09/2024

NARRATIVE

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Water temperature measured within regulation between 105 and 120 degrees F at faucets accessible to residents. There was enough lighting in all common areas, resident rooms, and hallways. Medication is centrally stored and locked.

Fire extinguishers located in the kitchen and hallways was last inspected 01/12/2024. Smoke alarm system and sprinkler system were last inspected 7/3/2024. The last Disaster Drill was conducted on 7/3/2024. Staff and 12 out of 14 resident records were reviewed. Administrator Certificate for Rashmika Mahawal, #6029802740 expired March 5, 2024 but was said to have been renewed. Staff have required First Aid and CPR certificates.

Updated copies of the following documents were requested for facility file and are to be submitted to CCL by 10/8/2024:

LIC500- Personnel Report
LIC9020- Register of residents
Evidence of Liability Insurance
Copy of current Administrator Certificate

No deficiencies cited during todays visit.

SUPERVISOR'S NAME: Kimberley Mota	TELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Araceli Canela	TELEPHONE: (707) 588-5041
LICENSING EVALUATOR SIGNATURE:	DATE: 09/09/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/09/2024

LIC809 (FAS) - (06/04)

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