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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 092700840
Report Date: 09/05/2023
Date Signed: 09/05/2023 03:22:06 PM


Document Has Been Signed on 09/05/2023 03:22 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 NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827



FACILITY NAME:VILLAGE OAKS SENIOR CARE, LLCFACILITY NUMBER:
092700840
ADMINISTRATOR:FOULK, BENJAMIN L.FACILITY TYPE:
740
ADDRESS:1011 ST. ANDREWS DRIVETELEPHONE:
(916) 293-1981
CITY:EL DORADO HILLSSTATE: CAZIP CODE:
95762
CAPACITY:15CENSUS: 14DATE:
09/05/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
01:50 PM
MET WITH:Administrator Jennifer Hinch TIME COMPLETED:
03:22 PM
NARRATIVE
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Licensing Program Manager (LPM) Laura Munoz and Licensing Program Analyst (LPA) Lavinia Muscan conducted a visit at Oak Hill Senior Care and met with Administrator Jennifer Hinch and explained the purpose of the visit. This report is being delivered at Oak Hill Senior Care for this facility.

Based on records reviewed it has been determined that Licensee has an overdue license fee. This facility has an outstanding balance for fees due. The current amount owed is $3,339.00 and was billed on 5/3/2023. As of this date, the fees are overdue. LPA explained to Administrator that proof of payment and/or proof of payment plan needs to be provided to CCL by the date given.

Per California Code of Regulations, Title 22 Division 6, Chapter 8, Type B deficiency is being cited today in violation of California Code of Regulations and follows on 809-D.

Exit interview conducted and appeal rights provided.

Report left at Oak Hill Senior Care.
SUPERVISOR'S NAME: Laura MunozTELEPHONE: (916) 263-4743
LICENSING EVALUATOR NAME: Lavinia MuscanTELEPHONE: 916-263-4700
LICENSING EVALUATOR SIGNATURE:
DATE: 09/05/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/05/2023
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 09/05/2023 03:22 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827


FACILITY NAME: VILLAGE OAKS SENIOR CARE, LLC
FACILITY NUMBER: 092700840

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/05/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/05/2023
Section Cited
HSC
1569.185(a)(1)

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1569.185 Fees for license or applications; use of revenues; collected; denial or forfeiture (a)(1) An application fee adjusted by facility and capacity shall be charged by the department for the issuance of a license to operate a residential care facility for the elderly. After initial licensure, a fee shall be charged by the department annually on each anniversary of the effective date of the license …
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By 10/5/23, the licensee shall contact Community Care Licensing to pay the entire fee due. Failure to correct shall result in civil penalties.
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This requirement has not been met as evidenced by: Based on department's review of annual fees not being paid. This does not pose an immediate risk to residents.

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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: Laura MunozTELEPHONE: (916) 263-4743
LICENSING EVALUATOR NAME: Lavinia MuscanTELEPHONE: 916-263-4700
LICENSING EVALUATOR SIGNATURE:
DATE: 09/05/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/05/2023
LIC809 (FAS) - (06/04)
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