486803614-1-21-2025-21-AS-BMOS-DDDUJD-20250129143723

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 486803614
Report Date: 01/21/2025
Date Signed: 01/21/2025 11:06:41 AM

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
10/04/2024 and conducted by Evaluator Christopher Arnhold

COMPLAINT CONTROL NUMBER: 21-AS-20241004094644

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:	DATE:	01/21/2025
		UNANNOUNCED	TIME BEGAN:	10:00 AM
MET WITH:	Theresa Ilagan (TJ)		TIME COMPLETED:	11:15 AM

ALLEGATION(S):

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9

Staff not properly trained to provide care to residents.

INVESTIGATION FINDINGS:

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At approximately 10:00AM, Licensing Program Analyst (LPA) Chris Arnhold arrived at this facility unannounced, to conduct an investigation into the above allegation. LPA met with Facility Manager Theresa Ilagan, toured the facility and reviewed documents. LPA spoke with Administrator Rose Mahawar via telephone during this visit. Based on records reviewed, Facility did not have documentation of 5 of 8 staff required training hours completed. LPA discussed the requirements for staff training hours with Administrator and provided a copy of regulation. All staff have received their training since the last visit.

Based on the Departments investigation, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED.
Deficiencies are cited from the California Code of Regulations (CCRs), and/or the Health and Safety Code. Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
This report was reviewed with House manager and Appeal rights were given.

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Bethany Moellers	TELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Christopher Arnhold	TELEPHONE: (707) 588-5084
LICENSING EVALUATOR SIGNATURE:	DATE: 01/21/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/21/2025

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

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
10/04/2024 and conducted by Evaluator Christopher Arnhold

COMPLAINT CONTROL NUMBER: 21-AS-20241004094644

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:	DATE:	01/21/2025
		UNANNOUNCED	TIME BEGAN:	10:00 AM
MET WITH:	Theresa Ilagan (TJ)		TIME COMPLETED:	11:15 AM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Facility does not have adequate staffing.
Facility is in disrepair

INVESTIGATION FINDINGS:

1
2
3
4
5
6
7
8
9
10
11
12
13

At approximately 10:00AM, Licensing Program Analyst (LPA) Chris Arnhold arrived at this facility unannounced, to conduct an investigation into the above allegations. LPA met with Facility Manager Theresa Ilagan, toured the facility and reviewed documents. LPA spoke with Administrator Rose Mahawar via telephone during this visit. Based on records reviewed and interviews conducted, the facility has staff to meet the residents needs. LPA reviewed staffing schedules and observed coverage on each shift. During the course of this investigation, LPA toured the building and observed several areas that were in need of repair. LPA was informed a project has already been planned and was to begin last year. However, due to an issue with a sister facility, the project was put on hold to accommodate the residents from the other facility. The areas in need of repair are not a danger to residents and the project will commence when the rooms are vacated.

Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are Unsubstantiated.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Bethany Moellers	TELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Christopher Arnhold	TELEPHONE: (707) 588-5084
LICENSING EVALUATOR SIGNATURE:	DATE: 01/21/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/21/2025

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

LIC9099 (FAS) - (06/04)

Page: 2 of 3

Control Number 21-AS-20241004094644

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: 01/21/2025

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 01/22/2025 Section Cited CCR 87412(c)	1 2 3 4 5 6 7	87412 Personnel Records:(c) Licensees shall maintain in the personnel records verification of required staff training and orientation. This requirement is not met as evidenced by: Based on records reviewed, Licensee did not have documentation of required staff training as required. This poses	1 2 3 4 5 6 7	Licensee reviewed staff training records and had all staff complete their required annual training. POC cleared at time of visit.
	8 9 10 11 12 13 14	a potential Health Safety or Personal rights risk to residents in care.	8 9 10 11 12 13 14
	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: Bethany Moellers	TELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Christopher Arnhold	TELEPHONE: (707) 588-5084
LICENSING EVALUATOR SIGNATURE:	DATE: 01/21/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/21/2025

LIC9099 (FAS) - (06/04)

Page: 3 of 3