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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 097005553
Report Date: 08/22/2023
Date Signed: 08/22/2023 02:58:14 PM


Document Has Been Signed on 08/22/2023 02:58 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:OAK CREEK SENIOR CAREFACILITY NUMBER:
097005553
ADMINISTRATOR:DR. BENJAMIN FOULKFACILITY TYPE:
740
ADDRESS:2908 TAM O'SHANTER DRIVETELEPHONE:
(916) 939-0962
CITY:EL DORADO HILLSSTATE: CAZIP CODE:
95762
CAPACITY:6CENSUS: 5DATE:
08/22/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
02:40 PM
MET WITH:Administrator Jennifer HinchTIME COMPLETED:
03:10 PM
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Licensing Program Analysts (LPAs) Lavinia Muscan and Jaynae Boyles arrived at the facility unannounced on 8/22/23 and met with Administrator Jennifer Hinch and explained the purpose of the visit.

Today's visit is to check the health and safety of residents in care after facility had to do Emergency Evacuation for one resident on 8/17/22 due to condensation build up, and leak, from a broken AC pipe at the facility. The leak was in one resident's room; room 4. Facility is working on the dry wall phase. LPAs did a brief tour of the facility and observed that there are no other issues at this time.

No deficiencies were observed or cited for this visit.

Exit interview conducted with Administrator and copy of the report left at the facility.

SUPERVISOR'S NAME: Laura MunozTELEPHONE: (916) 263-4743
LICENSING EVALUATOR NAME: Lavinia MuscanTELEPHONE: 916-263-4700
LICENSING EVALUATOR SIGNATURE:
DATE: 08/22/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/22/2023
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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