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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 557005530
Report Date: 07/22/2022
Date Signed: 07/24/2022 10:25:58 PM


Document Has Been Signed on 07/24/2022 10:25 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
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833



FACILITY NAME:OAK TERRACE MEMORY CAREFACILITY NUMBER:
557005530
ADMINISTRATOR:ILONA ROZA CORPUSFACILITY TYPE:
740
ADDRESS:20420 RAFFERTY CTTELEPHONE:
(209) 533-4822
CITY:SOULSBYVILLESTATE: CAZIP CODE:
95372
CAPACITY:42CENSUS: 7DATE:
07/22/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
01:15 PM
MET WITH:Medication Technician, Macy MishtavyTIME COMPLETED:
02:45 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 Analyst (LPA) Sarah Hurt arrived at the care facility at 01:15 p.m. and met with Medication Technician, Macy Mishtavy to conduct a Case Management visit into incident reports from July 11, 2022, and a separate incident on July 19, 2022.

LPA received an incident report documenting on 07/11/2022 Resident 1 was able to leave the facility unaccompanied, and was found walking on 108 road at approximately 1:35 a.m. Resident 1 was returned to the community via local EMS.

According to R1's Physicians report (602), R1 is not allowed to leave the facility unassisted.

LPA was recently informed that facility Resident 2 has been touching female residents in an inappropriate manner. On 07/19/2022 at 11:00 a.m. Resident 2 was discovered in the TV lounge area with Resident 3. Facility staff was alerted and it was discovered Resident 2 was inappropriately touching Resident 3. Resident 2 was sent to the ER for re evaluation, and police were contacted. Resident 2 has had several recent episodes of displaying inappropriate behavior towards other female residents, and staff. Resident 2 is still currently living at the facility.

The following deficiencies were cited during today’s visit.

You are hereby assessed an immediate civil penalty in the amount of $500.00.


Exit interview conducted with facility Medication Technician, Macy Mishtavy and appeal rights given.
SUPERVISOR'S NAME: Stephenie DoubTELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Sarah HurtTELEPHONE: (916) 879-2602
LICENSING EVALUATOR SIGNATURE:
DATE: 07/22/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/22/2022
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