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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 557001183
Report Date: 04/24/2024
Date Signed: 04/24/2024 03:46:32 PM

Document Has Been Signed on 04/24/2024 03:46 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:VALLEY OAKS FAMILY HOMEFACILITY NUMBER:
557001183
ADMINISTRATOR/
DIRECTOR:		MONA B. GASKILLFACILITY TYPE:
735
ADDRESS:16649 ANDERSON ROADTELEPHONE:
(209) 928-1196
CITY:SONORASTATE: CAZIP CODE:
95370
CAPACITY: 8CENSUS: DATE:
04/24/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
02:05 PM
MET WITH:Mona GaskillTIME VISIT/
INSPECTION COMPLETED:
04:00 PM
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On 4/24/24 Licensing Program Analyst (LPA) Maja Jensen arrived at facility unannounced to conduct a case management visit regarding an incident report that was received related to an allegation of a resident personal rights violation. LPA Jensen met with Mona Gaskill and explained the purpose of today's visit.

LPA Jensen requested copies of the staff file for staff 1 (S1) and a copy of the resident file for resident 1 (R1). LPA Jensen also requested a copy of staff roster with contact information, the resident roster with responsible party information and a staff schedule. The Licensee will email the rosters to LPA Jensen.

LPA Jensen interviewed the Licensee and determined that the Licensee immediately reported to all required parties upon learning of the alleged personal rights violation. The Licensee also took all actions necessary to safeguard the resident. This incident will require additional time to investigate. An exit interview was conducted and a copy of this report was provided.
SUPERVISORS NAME: Lisa Rios
LICENSING EVALUATOR NAME: Maja Jensen
LICENSING EVALUATOR SIGNATURE: DATE: 04/24/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/24/2024
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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