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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 097001635
Report Date: 12/10/2024
Date Signed: 12/10/2024 10:17:47 AM

Document Has Been Signed on 12/10/2024 10:17 AM - 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: 4DATE:
12/10/2024
TYPE OF VISIT:Case Management - Health ChecksUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:16 AM
MET WITH:RCC Serge EntonaTIME VISIT/
INSPECTION COMPLETED:
10:30 AM
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Licensing Program Analyst (LPA) Lavinia Muscan arrived at the facility unannounced on 12/10/24 to conduct a health and safety check. LPA met with RCC Serge Entona and explained the purpose of the visit.

During today's visit, the Department checked the food supply and did a brief walk through the facility with staff. No concerns noted.

No citations were issued per Title 22 Regulations.

Exit interview conducted and copy of the report left at facility.
SUPERVISORS NAME: Laura Munoz
LICENSING EVALUATOR NAME: Lavinia Muscan
LICENSING EVALUATOR SIGNATURE: DATE: 12/10/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/10/2024
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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