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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 097001794
Report Date: 03/11/2020
Date Signed: 12/08/2021 07:09:00 AM

Document Has Been Signed on 12/08/2021 07:09 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
, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
FACILITY NAME:OAK HILL SENIOR CAREFACILITY NUMBER:
097001794
ADMINISTRATOR:MARY FLEEMANFACILITY TYPE:
740
ADDRESS:2910 TAM O'SHANTER DRIVETELEPHONE:
(916) 939-0962
CITY:EL DORADO HILLSSTATE: CAZIP CODE:
95762
CAPACITY: 6CENSUS: 3DATE:
03/11/2020
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Rod FleemanTIME COMPLETED:
11:00 AM
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(3) Unannounced annual visit performed by LPA Michael Smith. Contact with Rod Fleeman.

Facility was toured both indoor and outdoors. Observed were the physical plant, food service, medication, client and staff records. The outside of the facility was observed to be in good repair and safe for residents. The inside of the facility was observed to be in good repair. Bathrooms and showers were clean and in good repair. Hot water temperature was 109'. Facility was maintained at a comfortable temperature. Required amounts of stored and perishable foods were present. Bedrooms were observed to be in good repair and bedding, storage and lighting were adequate. Medication, chemicals and toxins were appropriately under lock and key. Smoke and carbon monoxide detectors were present. Facility is equipped with a fire sprinkler suppression system and a central pull fire alarm. Fire extinguishers were fully charged and ready for emergency use. First aid kit was fully stocked for use. Facility license was openly posted for viewing. Administrator certificate for Susan M Cadena was observed to be current and expires 11/1/20. Three staff and 3 resident’s records were reviewed. Facility has 3 non-ambulatory residents and this accounting is within fire clearance allowances.

A review of staff records on 3/11/20 indicates that all facility staff and other individuals who require caregiver background checks have received criminal record clearances.

As a result of this visit, there were no deficiencies.

Exit interview conducted.
SUPERVISORS NAME: Troy Ordonez
LICENSING EVALUATOR NAME: Michael Smith
LICENSING EVALUATOR SIGNATURE: DATE: 03/11/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/11/2020
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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