Community Care Licensing

Document Has Been Signed on 04/05/2023 11:43 AM - It Cannot Be Edited

FACILITY NAME:	OAK CREEK SENIOR CARE		FACILITY NUMBER:	097005553
ADMINISTRATOR:	DR. BENJAMIN FOULK		FACILITY TYPE:	740
ADDRESS:	2908 TAM O'SHANTER DRIVE		TELEPHONE:	(916) 939-0962
CITY:	EL DORADO HILLS	STATE: CA	ZIP CODE:	95762
CAPACITY: 6		CENSUS: 5	DATE:	04/05/2023
TYPE OF VISIT:	Annual/Random	UNANNOUNCED	TIME BEGAN:	09:30 AM
MET WITH:	Rod Fleeman		TIME COMPLETED:	12:00 PM

SUPERVISORS NAME: Maribeth Senty LICENSING EVALUATOR NAME: Melissa Parks LICENSING EVALUATOR SIGNATURE: DATE: 04/05/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/05/2023

Link to Parent Document Below:

FACILITY NAME: OAK CREEK SENIOR CARE	FACILITY NUMBER: 097005553
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 04/05/2023

Type B

Section Cited

CCR

87463(c)

(c) The licensee shall arrange a meeting with the resident, the resident's representative, if any, appropriate facility staff, and a representative of the resident's home health agency, if any, when there is significant change in the resident's condition, or once every 12 months, whichever occurs first, as specified in Section 87467, Resident Participation in Decision Making. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above in 2 out of 5 resident files reviewed did not contain reappraisals which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 04/26/2023
	Plan of Correction
1 2 3 4	Facility to complete forms, stored in resident binds, and submitted to LPA

Type B

Section Cited

CCR

87555(b)(26)

(b) The following food service requirements shall apply: (26) Supplies of nonperishable foods for a minimum of one week and perishable foods for a minimum of two days shall be maintained on the premises. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above based on majority of food kept in locked garage at neighboring facility which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 05/03/2023
	Plan of Correction
1 2 3 4	Facility to supply pantry and refrigerator with additional food to comply with regulation. Facility to submit pictures to LPA

SUPERVISOR'S NAME: Maribeth Senty LICENSING EVALUATOR NAME: Melissa Parks LICENSING EVALUATOR SIGNATURE: DATE: 04/05/2023

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/05/2023

Link to Parent Document Below:

FACILITY NAME: OAK CREEK SENIOR CARE	FACILITY NUMBER: 097005553
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 04/05/2023

Type B

Section Cited

CCR

87625(b)(3)

(b) In addition to Section 87611, General Requirements for Allowable Health Conditions, the licensee shall be responsible for the following: (3) Ensuring that incontinent residents are kept clean and dry and that the facility remains free of odors from incontinence. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on interview], the licensee did not comply with the section cited above due to 2 incontinent residents not receiving services from 10pm to 6am which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 05/05/2023
	Plan of Correction
1 2 3 4	Facility to submit staffing plan to manage incontinence during overnight shift

Section Cited

	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

SUPERVISOR'S NAME: Maribeth Senty LICENSING EVALUATOR NAME: Melissa Parks LICENSING EVALUATOR SIGNATURE: DATE: 04/05/2023

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/05/2023