486803614-5-9-2023-21-AS-CMAZ-CRRKQV-20230512080659

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 486803614
Report Date: 05/09/2023
Date Signed: 05/09/2023 12:28:37 PM

Unsubstantiated

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
11/30/2022 and conducted by Evaluator David Leibert

COMPLAINT CONTROL NUMBER: 21-AS-20221130135859

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: 18	DATE:	05/09/2023
		UNANNOUNCED	TIME BEGAN:	12:37 PM
MET WITH:	Facility Manager,Theresa Ilagan		TIME COMPLETED:	01:30 PM

ALLEGATION(S):

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Staff had no knowledge of the resident medical condition and/or medical history.
Facility is not meeting residents care needs

INVESTIGATION FINDINGS:

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Licensing Program Analyst Leibert arrived unannounced for the purpose of delivering findings on this complaint. LPA met with Facility Manager and discussed the allegations. During the course of this investigation, statements were taken from staff and documents were obtained and reviewed. Attempts to contact the Complainant in order to obtain a statement and clarify information was unsuccessful. Both phone numbers listed in the case file are not valid, on have been disconnected and the other is not a number for the Complainant. A letter was sent to the Complainant at the listed address requesting contact on April 17, 2023 but no response has been received. Facility staff deny the allegations and have indicated the paramedics appeared at the facility unannounced in order to transfer the complaint subject to another facility. Staff indicate the delay in preparing the subject for transport resulted from the lack of notification of the date and time of transport. While not all requested records were provided to paramedics, staff statements and facility records suggest staff were aware of resident's condition and meeting resident's needs. Although the allegations may be true, based on statements and records, there is not a preponderance of evidence to prove the allegations true or, not true. Therefore, the allegations are UNSUBSTANTIATED. Report left. No citations issued.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Carla Martinez	TELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: David Leibert	TELEPHONE: (707) 588-5086
LICENSING EVALUATOR SIGNATURE:	DATE: 05/09/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/09/2023

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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