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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 507203056
Report Date: 11/17/2022
Date Signed: 11/22/2022 11:06:20 AM

Document Has Been Signed on 11/22/2022 11:06 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:
11/17/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:30 AM
MET WITH:Maria DentonTIME COMPLETED:
01:00 PM
NARRATIVE
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Unannounced annual visit made out to this facility on 11/17/2022 by Licensing Program Analyst (LPA) Charlie Yang who was met by the facility designated Administrator Maria Denton who was briefly interviewed. It was learned that this facility accepted and retained adults, age range 18-59 years of age, and was not vendorized at this time.
Current census was 5 residents.
Tour of this facility was conducted.
Dining area, living area, and all other areas intended for resident use were observed to be furnished and maintained in compliance at this time.
A tour of the front resident bedroom was conducted. 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 restroom was conducted. Hot water temperature was taken and measured to make sure that it was within the allowed range of 105-120 degrees.
Fire extinguisher, located hanging in the hallway, was observed to have been annually inspected on 11/09/2022 by the local fire extinguisher company, Jorgensen Company, and in compliance at this time.
Kitchen area was toured. Cabinets and drawers were reviewed.
Food supply was reviewed to make sure that there was an adequate supply of 2-day perishable and 7-day nonperishable quantities at all times.
Medication cart, located in the kitchen area, was observed to be locked and made inaccessible to the residents at this time. A brief review of the medications and dispensing policies and procedures were discussed with the facility designated Administrator at this time.
First aid kit, located in a kitchen cabinet, was observed to be present and contained all of the required components at this time.
A tour of the resident bedrooms 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.
SUPERVISORS NAME: Stephenie Doub
LICENSING EVALUATOR NAME: Charlie Yang
LICENSING EVALUATOR SIGNATURE: DATE: 11/17/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/17/2022
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: 11/17/2022
NARRATIVE
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Linen closet, located in facility hallway leading to the resident bedrooms, was observed to be supplied with a sufficient supply of blankets, towels, and bedspreads at this time.
Laundry area was observed to have cabinets that were locked to make cleaning and laundry supplies inaccessible to the residents at this time.
Garage area was toured.
Exterior grounds of this facility was reviewed. A review of the facility perimeter fence, side gates, and exits was conducted.

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 at this time.

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

DATE: 11/17/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/17/2022
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 11/22/2022 11:06 AM - It Cannot Be Edited


Created By: Charlie Yang On 11/17/2022 at 12:57 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: 11/17/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
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 several window screens were missing from resident bedrooms which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/24/2022
Plan of Correction
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Facility designated Administrator stated that the window screens that were deemed to be missing would be replaced so that all resident bedroom windows would have functional window screens in good repair at all times. A statement of correction, along with copies of receipts for the new window screen replacements, will be completed and submitted into CCL by the due date.
Type B
Section Cited
CCR
80088(e)(3)
Fixtures, Furniture, Equipment, and Supplies
(e) Faucets used by clients for personal care such as shaving and grooming shall deliver hot water. (3) All toilets, handwashing and bathing facilities shall be maintained in safe and sanitary operating condition. Additional equipment, aids, and/or conveniences shall be provided in facilities accommodating physically handicapped clients who need such items.

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 [1] out of [3] toilets reviewed showed that it was leaking water and was in need of repair which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/24/2022
Plan of Correction
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Facility designated Administrator stated all restroom toilets will be reviewed and if any are found to be leaking and in need of repair/replacement, they will be repaired/replaced at this time. A statement of correction, along with copies of all contracted work and parts purchased, 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: 11/17/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/17/2022


LIC809 (FAS) - (06/04)
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