<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 507203056
Report Date: 11/07/2023
Date Signed: 11/07/2023 02:57:48 PM

Document Has Been Signed on 11/07/2023 02:57 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: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:
11/07/2023
TYPE OF VISIT:Case Management - Health ChecksUNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Maria Denton, AdministratorTIME COMPLETED:
03:15 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
On 11/07/23, Licensing Program Analysts (LPA's) Renee Campbell and Ruth Wallace arrived unannounced to conduct a case management visit at approximately 1:30 PM based on a prior annual visit.

LPA Campbell was let in by Resident 1 (R1) and observed the facility live-in caregiver, Staff 1 (S1) on the couch. Administrator, Maria Denton arrived 15 minutes later. The medicine cabinet was observed by LPA Campbell unlocked and the key was left in the cabinet lock. S1 was notified of the unlocked cabinet, it was locked up immediately and S1 removed the key. LPA Campbell walked through the facility and observed that the resident’s toilet was clear of urine stains and the bathroom floor had been mopped. Cleaning products were locked in the bottom cabinet with an intact lock. The dining room table and chandelier had been dusted. LPA will continue to follow up with this facility and its designated Administrator in regard to these issues.

Per California Code of Regulations (CCRs) - Title 22, Division 6, Chapter 6, the following deficiency are being cited on the attached 809-D during this visit.
If the cited deficiency is not corrected by the noted due dates; civil penalties may be assessed. The Facility Designee was provided a copy of their rights (LIC 9058) and their signature on this form acknowledges receipt of these rights.
An exit interview was conducted, a copy of the report was given.
SUPERVISORS NAME: Lisa Rios
LICENSING EVALUATOR NAME: Renee Campbell
LICENSING EVALUATOR SIGNATURE: DATE: 11/07/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/07/2023
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 2
Document Has Been Signed on 11/07/2023 02:57 PM - It Cannot Be Edited


Created By: Renee Campbell On 11/07/2023 at 01:55 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
, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: STANDING OAK MANOR
FACILITY NUMBER: 507203056

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/07/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
11/07/2023
Section Cited
CCR
80075(k)(1)

1
2
3
4
5
6
7
Health Related Services: (k)(1) Medication shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication.
This requirement is not met as evidenced by:
1
2
3
4
5
6
7
During the visit, LPA observed the licensee close and lock the medication cabinet and remove the key from the lock, therefore, no further action taken.
8
9
10
11
12
13
14
Based on observation and interview, the licensee did not ensure medication was kept in a safe and locked place.

This poses a potential Health, Safety or personal rights risk to residents in care.
8
9
10
11
12
13
14

1
2
3
4
5
6
7
1
2
3
4
5
6
7

1
2
3
4
5
6
7
1
2
3
4
5
6
7
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:Lisa Rios
LICENSING EVALUATOR NAME:Renee Campbell
LICENSING EVALUATOR SIGNATURE:
DATE: 11/07/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/07/2023


LIC809 (FAS) - (06/04)
Page: 2 of 2