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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 097001794
Report Date: 12/20/2021
Date Signed: 12/21/2021 09:03:27 AM

Document Has Been Signed on 12/21/2021 09:03 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
CCLD Regional Office, 520 COHASSET RD., STE. 170
CHICO, CA 95926
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: 6DATE:
12/20/2021
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Priya LalTIME COMPLETED:
10:30 AM
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Unannounced annual visit utilizing the infection control domain was performed by LPA Michael Smith. Contact with Priya Lal.

A review of staff records on 12/20/21 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. However, 1 technical advisory was issued.

Exit interview conducted.
SUPERVISORS NAME: Laura Munoz
LICENSING EVALUATOR NAME: Michael Smith
LICENSING EVALUATOR SIGNATURE: DATE: 12/20/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/20/2021
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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