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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 097001794
Report Date: 04/26/2023
Date Signed: 04/26/2023 02:35:12 PM

Document Has Been Signed on 04/26/2023 02:35 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 HILL SENIOR CAREFACILITY NUMBER:
097001794
ADMINISTRATOR:OMITA KHANFACILITY TYPE:
740
ADDRESS:2910 TAM O'SHANTER DRIVETELEPHONE:
(916) 939-0962
CITY:EL DORADO HILLSSTATE: CAZIP CODE:
95762
CAPACITY: 6CENSUS: 5DATE:
04/26/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Rod FleemanTIME COMPLETED:
02:45 PM
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Licensing Program Analyst (LPA) Melissa Parks arrived at the facility on Wednesday April 26, 2023 to conduct a case management visit.

LPA reviewed staff files (2) and resident files (5). All staff files contained the required paperwork and training. All resident files contained the required paperwork. LPA verified that the facility had 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: Maribeth Senty
LICENSING EVALUATOR NAME: Melissa Parks
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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