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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 507005604
Report Date: 08/29/2024
Date Signed: 08/29/2024 03:15:19 PM


Document Has Been Signed on 08/29/2024 03:15 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827



FACILITY NAME:ASTORIA AT OAKDALEFACILITY NUMBER:
507005604
ADMINISTRATOR:JACQUELINE HERNANDEZFACILITY TYPE:
740
ADDRESS:700 LAUREL AVETELEPHONE:
(209) 847-0864
CITY:OAKDALESTATE: CAZIP CODE:
95361
CAPACITY:45CENSUS: 36DATE:
08/29/2024
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
03:00 PM
MET WITH:Jacqueline HernandezTIME COMPLETED:
03:45 PM
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On 8/29/24 Licensing Program Analyst (LPA) Maja Jensen arrived at facility unannounced to conduct a case management. LPA Jensen met with Executive Director Jacqueline Hernandez and explained the purpose of the visit.

As part of separate complaint investigation (see complaint # 27-AS-20240607111426) LPA Jensen reviewed resident records for Resident 1 (R1). The records reviewed included Medication Administration Records, Physician communication forms, Physician Report, Needs and Service Plan, Observation Records and Task administration records. Based on the record review it was learned that their were numerous occasions documented between May 4th and June 4th wherein R1 refused medications, refused assistance with toileting and refused assistance with grooming. This change in behavior constitutes a change in R1's condition and as such warrants obtaining a new medical assessment.

Consultation was provided (see LIC 9102)

An exit interview was conducted and a copy of this report was provided.

SUPERVISOR'S NAME: Lisa RiosTELEPHONE: (916) 969-9685
LICENSING EVALUATOR NAME: Maja JensenTELEPHONE: (916) 639-5584
LICENSING EVALUATOR SIGNATURE:
DATE: 08/29/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/29/2024
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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