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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 557005530
Report Date: 06/03/2021
Date Signed: 06/04/2021 06:55:03 AM

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:OAK TERRACE MEMORY CAREFACILITY NUMBER:
557005530
ADMINISTRATOR:JACOB PRIMEAUFACILITY TYPE:
740
ADDRESS:20420 RAFFERTY CTTELEPHONE:
(209) 533-4822
CITY:SOULSBYVILLESTATE: CAZIP CODE:
95372
CAPACITY:42CENSUS: 18DATE:
06/03/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:05 PM
MET WITH:ADMINISTRATOR - JACOB PRIMEAUTIME 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
Licensing Program Analysts (LPA's) Sarah Hurt and Ruth Wallace made an unannounced visit on this day for the purpose of conducting a Required - 1 Year Evaluation. LPA's met with Administrator Jacob Primeau. Administrator's Certificate which expires 9/27/21.

LPA's toured the facility grounds with Administrator. LPA's inspected 4 resident bedrooms. Bathrooms and hand washing areas were observed clean and sanitary. Non-slip textured surfaces were observed in shower. Water temperature measured at 115.8 F. Smoke detectors observed operational. The facility also has sprinkler system. Fire extinguishers were observed mounted and expire 11/6/2021. The facility was at a comfortable temperature for residents in care. LPA's observed required postings in prominent area for residents to view. LPA's reviewed food services and observed enough food on hand to meet the 2 day perishable, 7 day non-perishable requirement. Medication administration was observed with no concerns noted. Medications were centrally stored and inaccessible to persons in care.
LPA's requested to review 2 resident files. Items reviewed but not limited to were: admission's agreement, Physician's reports, Needs and Services plans and TB tests, with no concerns noted.
LPA's requested to review 2 staff files. Items reviewed but not limited to were health screening, TB test and Fingerprint Clearance as well as annual training with no concerns noted.
LPA reviewed emergency preparedness procedures with no concerns noted. Administrator reported that, the generator is tested monthly.

Based on observations of the LPA's, the facility appears to be in substantial compliance with Title 22 Division 6 of the California Code of regulations. An exit interview was conducted with Administrator and a copy of this report was provided along with a confidential list of staff and resident files reviewed.
SUPERVISOR'S NAME: Stephenie DoubTELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Sarah HurtTELEPHONE: (916) 879-2602
LICENSING EVALUATOR SIGNATURE:

DATE: 06/03/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/03/2021
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 1