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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486803614
Report Date: 08/19/2022
Date Signed: 08/22/2022 11:19:33 AM


Document Has Been Signed on 08/22/2022 11:19 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 CAREFACILITY NUMBER:
486803614
ADMINISTRATOR:MAHAWAR, RASHMIKAFACILITY TYPE:
740
ADDRESS:1025 OAKWOOD AVENUETELEPHONE:
(707) 643-0473
CITY:VALLEJOSTATE: CAZIP CODE:
94591
CAPACITY:30CENSUS: 12DATE:
08/19/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:05 AM
MET WITH:Theresa ilagan, Facility ManagerTIME COMPLETED:
02:45 PM
NARRATIVE
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Licensing Program Analyst (LPA) Araceli Canela arrived unannounced to conduct an Annual Required 1 Year inspection and met with facility care staff, Maybelle Conge. Office manager, Theresa ilagan "TJ" arrived a few minutes later and Administrator, Rashmika Mahawar was not present during inspection. The inspection is focused on the Infection Control procedures and practices of this facility.

Upon arrival, LPA observed residents were engaged in activities posters outside notifying visitors that mask must be worn in the facility. Once inside, LPA was screened by a caregiver. LPA confirmed that facility is conducting vaccination verification per Provider Information Notice (PIN) 21-40-ASC. LPA initiated a walk-through of the facility and observed the following: Facility has COVID-19 posters throughout that included hand washing signs in bathrooms. Facility was a comfortable temperature. Hand sanitizer is located tin the front area only as residents lack hazard awareness. LPA observed staff had masks on during this visit. Commonly touched surfaces are disinfected daily and after use. Facility documents and continues to screen residents daily and staff when they come on shift.

Facility has a designated visitation area outside and is allowing for visitation in resident rooms per CCL guidance. Staff continue to be trained on infection control and Personal Protective Equipment, but have not been N95 fit tested.
Facility has submitted and CCL has reviewed their Covid Mitigation Plan. Facility has more than a 30 day supply of Personal Protective Equipment (PPE) including but not limited to masks, gowns, and hand sanitizer. Facility maintains a 30 day supply of medication. Fire extinguishers were last serviced February 2022.

Continued on LIC809C

SUPERVISOR'S NAME: Kimberley MotaTELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Araceli CanelaTELEPHONE: (707) 588-5041
LICENSING EVALUATOR SIGNATURE:
DATE: 08/19/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/19/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 5


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: 08/19/2022
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Continued from LIC809C

Office Manager and LPA discussed their Emergency Disaster Plan. Facility has submitted their Infection Control Plan.

LPA consulted regarding required poster PUB475 that needs to be enlarged and placed in area visible to all residents and visitors. Poster was observed behind other posters in front office space. LPA consulted regarding how to maintain records.

Facility has two wings and is licensed for 30 residents and during todays visit the push buttons to call staff were not functional.

LPA will review documents and fire clearance for side internal doors and exterior door protocol and fire department approval, along with front door delay egress that is used by push button, rather than push door. LPA tested front door and door is able to be opened after a small button located on right side of door is pushed - LPA advised staff not to cover button and button must be visible to ALL.

Licensee/Administrator to submit updates of the following documents by 09/19/2022:

LIC 308 Designation of Responsibility.
LIC 500 Personnel Summary
LIC 610 Emergency Disaster Plan
LIC 9020 Register of Facility Client’s/Resident’s
Copy of current Administrator's Certificate
Copy of current Lease/Rental Agreement
Copy of Liability Insurance


See report LIC809-D for 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. A civil penalty was applied for $500.00 for fire safety, Zero Tolerance.
SUPERVISOR'S NAME: Kimberley MotaTELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Araceli CanelaTELEPHONE: (707) 588-5041
LICENSING EVALUATOR SIGNATURE:

DATE: 08/19/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/19/2022
LIC809 (FAS) - (06/04)
Page: 2 of 5
Document Has Been Signed on 08/22/2022 11:19 AM - It Cannot Be Edited

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

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/19/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87203
87203 Fire Safety All facilities shall be maintained in conformity with the regulations adopted by the State Fire Marshal for the protection of life and property against fire and panic.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on todays inspection LPA observed 2 of 12 resident bedroom sliding door with a chest of drawers by the side of the door, which limits the amount of space available for a resident to exit safely. LPA also observed resident R1s sliding door does not open, LPA attempted with staff S2. Door appears to be jammed which poses an immediate health, safety or personal rights risk to persons in care. A civil penalty for $500.00 was applied during today's inspection for Fire Safety violation- Zero Tolerance.
POC Due Date: 08/20/2022
Plan of Correction
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During visit the door was un-jammed, but does not lock. Facility to send proof resident R1s sliding door is able to open and close properly and resident R2, R3 sliding door area is clear and move dresser near exit door. Facility to send in written plan on how they will stay in compliance, staff training to ensure staff know requirements and fire safety protocols in ensuring all exit doors are not obstructed or unable to open. POC due date for written statement due 8/20/2022 and staff training 8/22/2022 to LPA A Canela
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: Araceli CanelaTELEPHONE: (707) 588-5041
LICENSING EVALUATOR SIGNATURE:
DATE: 08/19/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/19/2022
LIC809 (FAS) - (06/04)
Page: 4 of 5


Document Has Been Signed on 08/22/2022 11:19 AM - It Cannot Be Edited

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

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/19/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87303(i)(1)(A)
87303(i)(1)(A)(i)
Facilities shall have signal systems which shall meet the following criteria:
(1) All facilities licensed for 16 or more and all residential facilities having separate floors or buildings shall have a signal system which shall:
(A) Operate from each resident's living unit.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on today's visit observation and review with Office Manager S1, the licensee did not comply with the section cited above in all resident bedrooms for 12 out of 12 resident pull cords were not working and when pulled, it did not alert staff as the main monitor was not operational during todays inspection, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/31/2022
Plan of Correction
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For Maintenance of Operation 87303(i)(1)(A) Facility to send in proof they have contacted a company or service to fix resident room pull cords and send in written plan how facility will stay in compliance.

POC due date 8/31/2022 to LPA A Canela
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: Araceli CanelaTELEPHONE: (707) 588-5041
LICENSING EVALUATOR SIGNATURE:
DATE: 08/19/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/19/2022
LIC809 (FAS) - (06/04)
Page: 5 of 5