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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 507203056
Report Date: 11/03/2021
Date Signed: 11/09/2021 10:32:42 AM

Document Has Been Signed on 11/09/2021 10:32 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, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
FACILITY NAME:STANDING OAK MANORFACILITY NUMBER:
507203056
ADMINISTRATOR:MARIA DENTONFACILITY TYPE:
735
ADDRESS:3770 STANDING OAK DRIVETELEPHONE:
(209) 541-1069
CITY:CERESSTATE: CAZIP CODE:
95307
CAPACITY: 6CENSUS: 5DATE:
11/03/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Maria DentonTIME COMPLETED:
12:30 PM
NARRATIVE
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Unannounced annual visit made out to this facility on 11/03/2021 by LPA Charlie Yang to conduct an annual inspection. This LPA was met by the facility personnel who was requested, by this LPA, to contact the facility designated Administrator, Maria Denton, to inform her that CCL was present at this time. The facility designated Administrator arrived shortly thereafter to this facility.
Current census was 5 residents.
This facility is licensed to accept and retain up to (6) residents at any given time. This facility is not vendorized, through Valley Mountain Regional Center, at this time.
Tour of this facility was conducted.
Medication cart, located in living area , was reviewed. Policies and procedures surrounding medications was discussed with the facility designated Administrator. First aid kit was observed to be present and contained all of the required components at this time.
Kitchen area was toured. Cabinets and drawers were reviewed to make sure that there was a sufficient amount of flatware, dinnerware, and items for resident use.
Food storage units were reviewed to make sure that there was a sufficient supply of 2-day perishable and 7-day nonperishable quantities at all times.
Garage area was toured.
Laundry area was toured. Laundry detergent, bleach, and all other cleaning supplies were observed to be locked and made inaccessible to the residents at this time.
A tour of the resident rooms was conducted. Resident bedroom furniture and furnishings were observed to be sufficient and able to meet the needs of the residents at this time.
A tour of the resident restrooms was conducted. Hot water temperatures were taken to make sure that they were within the allowed range of 105-120 degrees.
Fire extinguisher, located in the hallway, was reviewed and observed to have been annually inspected on 12/04/2019 by the local fire extinguisher company.
Linen closet, located in hallway, was reviewed and observed to contain a sufficient amount of linens to meet
SUPERVISORS NAME: Stephenie Doub
LICENSING EVALUATOR NAME: Charlie Yang
LICENSING EVALUATOR SIGNATURE: DATE: 11/03/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/03/2021
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, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
FACILITY NAME: STANDING OAK MANOR
FACILITY NUMBER: 507203056
VISIT DATE: 11/03/2021
NARRATIVE
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the needs of the residents at this time.
Common areas were toured. Living room, dining area and all other areas intended for resident use were observed to be furnished and maintained in compliance at this time.
Exterior grounds of this facility was toured. Perimeter fence and the main gate was observed to be maintained in good repair and in compliance at this time.

The following forms and documents were requested to be updated and submitted into CCL:

LIC 308

LIC 400

LIC 500

LIC 610

The following deficiencies were observed and cited on the following LIC 809-D pursuant to Title 22 Rules and Regulations, Health and Safety Code.

Appeal rights were printed and a copy was given to the facility designated Administrator.

Exit Interview
SUPERVISORS NAME: Stephenie Doub
LICENSING EVALUATOR NAME: Charlie Yang
LICENSING EVALUATOR SIGNATURE:

DATE: 11/03/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/03/2021
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 11/09/2021 10:32 AM - It Cannot Be Edited


Created By: Charlie Yang On 11/03/2021 at 12:19 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

FACILITY NAME: STANDING OAK MANOR
FACILITY NUMBER: 507203056

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/03/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80087(a)
Building and Grounds
(a) The facility shall be clean, safe, sanitary and in good repair at all times for the safety and well-being of clients, employees and visitors.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in the resident restrooms which were in disrepair which posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/10/2021
Plan of Correction
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Facility representative stated that the resident restrooms will be updated to repair and replace the broken toilet seat in the first restroom off of the front door. In addition, all restrooms will be reviewed and repaired as needed. A statement of correction, along with a copy of the receipt for repair services, will be completed and submitted into CCL by the due date.
Type B
Section Cited
CCR
80088(b)
Fixtures, Furniture, Equipment, and Supplies
(b) All window screens shall be in good repair and be free of insects, dirt and other debris.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in that the exterior window screens were ripped, torn, or had holes in them which posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/10/2021
Plan of Correction
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Facility representative stated that all window screens will be reviewed and replaced. A statement of correction, along with a copy of the receipt for repair services, will be completed and submitted into CCL by the due date.
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:Stephenie Doub
LICENSING EVALUATOR NAME:Charlie Yang
LICENSING EVALUATOR SIGNATURE:
DATE: 11/03/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/03/2021


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