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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 557005530
Report Date: 02/22/2023
Date Signed: 02/28/2023 01:07:37 PM


Document Has Been Signed on 02/28/2023 01:07 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 AC/SC, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833



FACILITY NAME:OAK TERRACE MEMORY CAREFACILITY NUMBER:
557005530
ADMINISTRATOR:CATHY HELTONFACILITY TYPE:
740
ADDRESS:20420 RAFFERTY CTTELEPHONE:
(209) 533-4822
CITY:SOULSBYVILLESTATE: CAZIP CODE:
95372
CAPACITY:42CENSUS: 0DATE:
02/22/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Mark CrowderTIME COMPLETED:
01:00 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
Unannounced annual visit conducted on 02/22/2023 by Licensing Program Analysts (LPAs), Charlie Yang and Kimberly Viarella. LPAs were met by the facility designated Administrator, Mark Crowder, and the Maintenance Director Mark Bridle.
Brief interview was conducted with the facility designated Administrator and Maintenance Director.
Current census was zero at this time.
This facility has not had any residents present since November 2022. LPAs began the inspection in the dining and kitchen area of building 1. There was adequate furniture in the dining area and knives were locked and secured in the kitchen.
As there were no residents in care at this time, the heat and hot water were turned down and a water temperature was not measured.
The maintenance tag for fire extinguishers were reviewed.
LPAs reviewed a sample of resident rooms, for both single and double occupancy.
Laundry rooms were also inspected and all cleaners laundry supplies were observed to be locked and made unavailable to residents at all times. Bathrooms contained grab bars and non slip surfaces.
The facility designated Administrator stated that all remaining medications were destroyed when the last resident vacated the facility, as per protocol.
The inspection continued with a walk-through of the second building which contained the administrative offices as well as additional resident bedrooms. There was adequate furniture and lighting throughout the facility.
LPAs toured the exterior grounds of the facility. At this time, the surrounding fence was in good repair and there were no bodies of water on the premises.

The following forms were requested to be updated and submitted in CCL for review by this LPA:
SUPERVISOR'S NAME: Liza KingTELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Charlie YangTELEPHONE: (916) 263-4700
LICENSING EVALUATOR SIGNATURE:
DATE: 02/22/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/22/2023
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


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO AC/SC, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
FACILITY NAME: OAK TERRACE MEMORY CARE
FACILITY NUMBER: 557005530
VISIT DATE: 02/22/2023
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
26
27
28
29
30
31
32
LIC 308

LIC 400

LIC 500

LIC 610

There were no deficiencies observed or cited at this time.

Closure plan was discussed with the facility designated Administrator Mark Crowder at this time.

Exit interview
SUPERVISOR'S NAME: Liza KingTELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Charlie YangTELEPHONE: (916) 263-4700
LICENSING EVALUATOR SIGNATURE:

DATE: 02/22/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/22/2023
LIC809 (FAS) - (06/04)
Page: 2 of 2