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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 097001635
Report Date: 04/26/2023
Date Signed: 04/26/2023 12:39:23 PM

Document Has Been Signed on 04/26/2023 12:39 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, 2525 NATOMAS PARK DR STE 270
SACRAMENTO, CA 95833
FACILITY NAME:OAK HAVEN SENIOR CAREFACILITY NUMBER:
097001635
ADMINISTRATOR:BENJAMIN L. FOULKFACILITY TYPE:
740
ADDRESS:2906 TAM O'SHANTER DRIVETELEPHONE:
(916) 941-7785
CITY:EL DORADO HILLSSTATE: CAZIP CODE:
95762
CAPACITY: 6CENSUS: 5DATE:
04/26/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
11:35 AM
MET WITH:Administrator Rod FleemanTIME COMPLETED:
12:45 PM
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Licensing Program Analysts (LPAs) Lavinia Muscan and Melissa Parks arrived on Wednesday April 26, 2023 to conduct a case management visit.

During the course of the facility visit, LPAs reviewed staff file (2) and resident files (4). One of the current residents is temporarily at this facility from a sister facility and their file was reviewed during a prior visit. LPAs observed the required training and paperwork in the staff files. LPAs observed the resident files to contain the required paperwork. LPAs observed 2 days of perishable food and 7 days of nonperishable food on hand.

Exit interview conducted. A copy of this report was left at the facility.
SUPERVISORS NAME: Laura Munoz
LICENSING EVALUATOR NAME: Lavinia Muscan
LICENSING EVALUATOR SIGNATURE: DATE: 04/26/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/26/2023
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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