486803614-3-12-2021-21-AS-KMOA-BZ7VEW-20210317162303

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 486803614
Report Date: 03/12/2021
Date Signed: 03/12/2021 05:05:53 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
12/14/2020 and conducted by Evaluator Araceli Canela

PUBLIC

COMPLAINT CONTROL NUMBER: 21-AS-20201214112258

FACILITY NAME:	OAKWOOD MEMORY & SENIOR CARE		FACILITY NUMBER:	486803614
ADMINISTRATOR:	ESTHER ZELEDON		FACILITY TYPE:	740
ADDRESS:	1025 OAKWOOD AVENUE		TELEPHONE:	(707) 643-0473
CITY:	VALLEJO	STATE: CA	ZIP CODE:	94591
CAPACITY:	30	CENSUS: 10	DATE:	03/12/2021
		UNANNOUNCED	TIME BEGAN:	12:45 PM
MET WITH:	Theresa iLagan"TJ"		TIME COMPLETED:	01:15 PM

ALLEGATION(S):

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Facility is in disrepair

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 3/12/2021 for the purpose of delivering findings on complaint investigation 21-AS-20201214112258. Due to COVID – 19 precautions a facility visit is not able to be conducted at this time.

It was alleged facility is in disrepair. During the investigation, LPA reviewed/obtained records, made facility observations via tele-visit, and conducted interviews with facility staff. Investigation revealed the facilities heater system stopped working and on 12/15/2020, they immediately purchased 7 portable heaters to use while they were able to get it fixed. Review of records indicate the heater system was also serviced on 1/7/2021 and facility states the issue was corrected. Investigation also revealed the laundry room is in disrepair, during a video visits on 3/4/2021 with house manager, Theresa iLagan"TJ" LPA observed the laundry room wall shows severe water damage and there were several holes on the ceiling, along with what appears like wood rot. It was reported to LPA and LPA received corroborating statements; the laundry room has been in that condition for more than half a year.

Continue report see LIC9099-C

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Kimberley Mota	TELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Araceli Canela	TELEPHONE: (707) 588-5041
LICENSING EVALUATOR SIGNATURE:	DATE: 03/12/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/12/2021

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-20201214112258

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: 03/12/2021

NARRATIVE

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Based on the received information the preponderance of evidence standard has been met, therefore the allegation for Facility is in disrepair, 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.
Report was emailed to obtain signature due to Covid-19 precautions.

SUPERVISOR'S NAME: Kimberley Mota	TELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Araceli Canela	TELEPHONE: (707) 588-5041
LICENSING EVALUATOR SIGNATURE:	DATE: 03/12/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/12/2021

LIC9099 (FAS) - (06/04)

Page: 2 of 4

Control Number 21-AS-20201214112258

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: 03/12/2021

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 04/12/2021 Section Cited CCR 87303(a)	1 2 3 4 5 6 7	87303(a) Maintenance and Operation (a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors.	1 2 3 4 5 6 7	Facility to send in written plan of action by 3/22/21 and proof of correction by POC date of 4/12/2021 to LPA A. Canela araceli.canela@dss.ca.gov
	8 9 10 11 12 13 14	This requirement was not met, as evidenced by: During the video inspection of 3/4/2021 and corroborating statements, LPA Observed the laundry room is in disrepair, water damage on walls, holes on ceiling and wood rot. This is a potential risk to the Health & safety of residents in care.	8 9 10 11 12 13 14	Failure to provide proof of correction by POC date, may result in civil penalty.
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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: Kimberley Mota	TELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Araceli Canela	TELEPHONE: (707) 588-5041
LICENSING EVALUATOR SIGNATURE:	DATE: 03/12/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/12/2021

LIC9099 (FAS) - (06/04)

Page: 3 of 4

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
12/14/2020 and conducted by Evaluator Araceli Canela

PUBLIC

COMPLAINT CONTROL NUMBER: 21-AS-20201214112258

FACILITY NAME:	OAKWOOD MEMORY & SENIOR CARE		FACILITY NUMBER:	486803614
ADMINISTRATOR:	ESTHER ZELEDON		FACILITY TYPE:	740
ADDRESS:	1025 OAKWOOD AVENUE		TELEPHONE:	(707) 643-0473
CITY:	VALLEJO	STATE: CA	ZIP CODE:	94591
CAPACITY:	30	CENSUS: 10	DATE:	03/12/2021
		UNANNOUNCED	TIME BEGAN:	12:45 PM
MET WITH:	Theresa iLagan"TJ"		TIME COMPLETED:	01:15 PM

ALLEGATION(S):

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Residents are not assisted with incontinence care on a timely basis

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 3/12/2021 for the purpose of delivering findings on complaint investigation 21-AS-20201214112258. Due to COVID – 19 precautions a facility visit is not able to be conducted at this time.
It was alleged residents are not assisted with incontinence care on a timely basis, due to the facility not having enough staff to provide the service and residents are left in soiled garments for longer periods of time. During the investigation, LPA reviewed/obtained records, made facility observations via tele-visit, and conducted interviews with facility staff. LPA was unable to get any statements from residents. LPA interviewed several staff and there were no corroborating statements made. LPA did receive statements that there is minimal staff and it gets very difficult for staff to complete their tasks and cannot take breaks in order to assist the residents. The Department has investigated the above allegations and at this time determined, although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the above allegation is Unsubstantiated.
No citations issued for this allegation. This report was emailed to facility to obtain signature.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Kimberley Mota	TELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Araceli Canela	TELEPHONE: (707) 588-5041
LICENSING EVALUATOR SIGNATURE:	DATE: 03/12/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/12/2021

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

LIC9099 (FAS) - (06/04)

Page: 4 of 4