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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 236804089
Report Date: 03/09/2023
Date Signed: 03/09/2023 12:44:25 PM

Document Has Been Signed on 03/09/2023 12:44 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
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME:OCEANSIDE CARE HOME LLCFACILITY NUMBER:
236804089
ADMINISTRATOR:OKORO, SYLVESTERFACILITY TYPE:
740
ADDRESS:535 E. CHESTNUT STREETTELEPHONE:
(707) 409-5004
CITY:FORT BRAGGSTATE: CAZIP CODE:
95437
CAPACITY: 6CENSUS: 4DATE:
03/09/2023
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
09:15 AM
MET WITH:Valesia ColeTIME COMPLETED:
01:00 PM
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At approximately 9:15AM, Licensing Program Analyst (LPA) Chris Arnhold arrived at this facility unannounced for the purpose of completing a pre-licensing evaluation. LPA met with Caregiver Valesia Cole and toured the facility. Applicant Sylvester Okoro received the Component III orientation on 11/03/2022 for another facility in the area. The facility is a 5 bedroom, 3 bathroom, single story home. Fire extinguishers were mounted and charged. Smoke detectors were tested and in working order. There was a locked area for medications and several for toxins and cleaning supplies. Beds were made with appropriate linens. Resident rooms contained the required furniture in 5 out of 5 rooms. Hot water temperature was tested and found to be within regulation between 105 degrees F and 120 degrees F at faucets accessible to residents. Exit doors had working alert devices installed.

At approximately 9:45AM, LPA reviewed 4 of 4 resident files and 2 of 2 staff records. Staff records contained documentation of the required annual training, including current First aid and CPR. Resident records contained the required information.

This facility has submitted a plan to care for residents with dementia. The plan has been reviewed and all physical plant safeguards have been checked. The applicant's states that they do not plan to advertise at this time. A fire clearance for this facility has been granted.

Component III orientation was conducted at facility.

Upon receipt of evidence of Liability Insurance, LPA will submit the application packet for a final review and approval from the Licensing Program Manager.
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Christopher Arnhold
LICENSING EVALUATOR SIGNATURE: DATE: 03/09/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/09/2023
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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