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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 097001635
Report Date: 10/08/2024
Date Signed: 10/08/2024 01:29:35 PM

Document Has Been Signed on 10/08/2024 01:29 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 HAVEN SENIOR CAREFACILITY NUMBER:
097001635
ADMINISTRATOR/
DIRECTOR:		BENJAMIN L. FOULKFACILITY TYPE:
740
ADDRESS:2906 TAM O'SHANTER DRIVETELEPHONE:
(916) 941-7785
CITY:EL DORADO HILLSSTATE: CAZIP CODE:
95762
CAPACITY: 6CENSUS: 3DATE:
10/08/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:30 AM
MET WITH:RCC Serge EntonaTIME VISIT/
INSPECTION COMPLETED:
01:45 PM
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Licensing Program Analyst (LPA) Lavinia Muscan arrived on 10/8/24 to conduct the annual inspection.

During today's annual inspection, the Compliance and Regulatory Enforcement Tool was used. LPA reviewed resident (3) and staff (2) files. All resident files contained the required paperwork. All staff files contained the required paperwork and training.

LPA and staff toured the facility together to ensure the health and safety of residents in care. The areas toured included, kitchen, hallway, resident rooms, resident dining room/kitchen, and resident common areas. Food is within compliance. Fire drills reviewed. Water temperature is within compliance. Fire extinguisher is ready for use. In the areas toured, there were no health or safety violations observed.

LPA requested a copy of the LIC500, LIC610E and current liability insurance to be sent to the Department by end of the month.

No deficiencies cited. Exit interview conducted. A copy of this report was left with RCC Serge Entona.
SUPERVISORS NAME: Laura Munoz
LICENSING EVALUATOR NAME: Lavinia Muscan
LICENSING EVALUATOR SIGNATURE: DATE: 10/08/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/08/2024
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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