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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486803614
Report Date: 07/29/2021
Date Signed: 07/29/2021 03:36:45 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		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 CAREFACILITY NUMBER:
486803614
ADMINISTRATOR:MAHAWAR, RASHMIKAFACILITY TYPE:
740
ADDRESS:1025 OAKWOOD AVENUETELEPHONE:
(707) 643-0473
CITY:VALLEJOSTATE: CAZIP CODE:
94591
CAPACITY:30CENSUS: DATE:
07/29/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:45 PM
MET WITH:Manager Teresa Lagan "TJ"TIME COMPLETED:
03:50 PM
NARRATIVE
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Licensing Program Analyst (LPA) Erik Gonzalez Campos arrived unannounced to conduct a Required - 1 Year inspection at approximately 12:45 PM, and met with manager Teresa iLagan "TJ". This inspection is focused on the Infection Control procedures and practices of this facility.

Upon entry LPA was asked to have their temperature taken and sign in by caregiver. At primary entrance LPA observed temperature logs and visitor sign-in sheet. LPA conducted walk through of the facility with care manager and observed COVID postings throughout. Mitigation plan was submitted and approved by Community Care Licensing (CCL).

During walk through of facility LPA asked about testing of staff. LPA was informed that staff member had been tested on July 22, 2021 and received a positive result on July 24, 2021. This had not been previously communicated to community care licensing (CCL).

Facility was a comfortable temperature and exits were free from obstructions. Plan is in place to isolate residents if they became ill. LPA confirmed facility has necessary PPE equipment and supplies to support a resident in isolation.

Residents' emergency contact information has been updated and manager confirmed staff are familiar with 911 procedures and protocols. Toxins are secured and inaccessible in locked housekeeping closet. A 30 day supply of medications are stored in locked medication room, making them inaccessible to residents.

Deficiencies 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. Appeal rights were provided.
SUPERVISOR'S NAME: Kimberley MotaTELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Erik Gonzalez CamposTELEPHONE: (707) 588-5026
LICENSING EVALUATOR SIGNATURE:

DATE: 07/29/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/29/2021
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, 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: 07/29/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87405(h)(3)
87405(h)(3) Administrator - Qualifications and Duties. (h) The administrator shall have the responsibility to: (3) Develop an administrative plan & procedures to ensure clear definition of lines of responsibility, equitable workloads, & adequate supervision.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on records review, observations and interviews conducted with staff, licensee failed to notify CCL and local DPH of Covid-19 after receiving notice of a positive (+) staff with COVID which poses an immediate health and safety risk to residents in care.
POC Due Date: 07/30/2021
Plan of Correction
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Licensee agrees to update Mitigation Plan and Licensee to ensure plan and policies are being followed. Licensee to ensure staff are trained on Mitigation plan and policies by July 30, 2021 and proof of local DPH being notified.
Licensee to submit training overview and list of staff trained to CCL by July 31, 2021.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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 MotaTELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Erik Gonzalez CamposTELEPHONE: (707) 588-5026
LICENSING EVALUATOR SIGNATURE:
DATE: 07/29/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/29/2021
LIC809 (FAS) - (06/04)
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