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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 092700840
Report Date: 06/23/2021
Date Signed: 06/23/2021 01:18:30 PM

Document Has Been Signed on 06/23/2021 01:18 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, 520 COHASSET RD., STE. 170
CHICO, CA 95926
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: DATE:
06/23/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Rodney Fleeman, administrator TIME COMPLETED:
01:15 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) Wolter arrived at the facility unannounced on 06/23/2021 to conduct a Required-1 Year Inspection utilizing the infection control domain, LPA met with administrator, Rodney Fleeman and explained the purpose of the visit. Prior to initiating the annual inspection, LPA completed required COVID-19 testing protocols, and a daily self-screening questionnaire for symptoms of COVID-19 infection to affirm no COVID-19 related symptoms and contacted facility and completed a facility risk assessment. LPA ensured they applied hand sanitizer before entering the facility and the following Personal Protective Equipment (PPE) was worn: N-95 Mask. Additionally, LPA utilized facility visitor sign in sheet with temperature screening upon entry.

LPA and administrator toured facility together to ensure health and safety of residents in care. Areas toured include but are not limited to: common areas, brief inspection of four (4) resident bedrooms, four (4) bathrooms and shower rooms, laundry room, and outdoor area. In the areas toured LPA observed cleaning supplies under the kitchen sink were unlocked and accessible, knives in kitchen cupboard were unlocked and accessible, and bleach was unlocked and accessible in the laundry room.

LPA and administrator completed the infection control domain and facility was found to be in substantial compliance at this time.

Deficiencies are being cited as a result of todays inspection.
Exit interview conducted and copy of report and appeal rights to be sent to administrator.

Administrator to send in updated copy of LIC 500 - Personnel Report, and current copy of Liability Insurance to Community Care Licensing by 07/02/2021.
SUPERVISORS NAME: Laura Munoz
LICENSING EVALUATOR NAME: Danyle Wolter
LICENSING EVALUATOR SIGNATURE: DATE: 06/23/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/23/2021
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 5
Document Has Been Signed on 06/23/2021 01:18 PM - It Cannot Be Edited


Created By: Danyle Wolter On 06/23/2021 at 12:27 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 520 COHASSET RD., STE. 170
CHICO, CA 95926

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

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/23/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87705(f)(2)
87705 Care of Persons with Dementia
(f) The following shall be stored inaccessible to residents with dementia: (2) Over-the-counter medication, nutritional supplements or vitamins, alcohol, cigarettes, and toxic substances such as certain plants, gardening supplies, cleaning supplies and disinfectants.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, the licensee did not comply with the section cited above, the facility has residents with a diagnosis of dementia and cleaning supplies and knives were observed to be unlocked and accessible which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 06/25/2021
Plan of Correction
1
2
3
4
Administrator locked cleaning supplies and knives during the visit. Additionally, administrator to hold an in-service training with staff on expectations of ensuring cleaning supplies and knives remain locked and inaccessible to residents. Documentation of staffs understanding to be sent to CCL by 06/25/2021.
Section Cited
Deficient Practice Statement
1
2
3
4
POC Due Date:
Plan of Correction
1
2
3
4
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 Munoz
LICENSING EVALUATOR NAME:Danyle Wolter
LICENSING EVALUATOR SIGNATURE:
DATE: 06/23/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/23/2021


LIC809 (FAS) - (06/04)
Page: 4 of 5