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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 347002205
Report Date: 08/29/2024
Date Signed: 08/29/2024 01:33:41 PM

Document Has Been Signed on 08/29/2024 01:33 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, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME:OAK GARDEN SENIOR RESIDENCEFACILITY NUMBER:
347002205
ADMINISTRATOR/
DIRECTOR:		ANTON, TEOFILFACILITY TYPE:
740
ADDRESS:6707 SUN DOWN COURTTELEPHONE:
(916) 944-0774
CITY:CARMICHAELSTATE: CAZIP CODE:
95608
CAPACITY: 6CENSUS: 5DATE:
08/29/2024
TYPE OF VISIT:Case Management - Annual ContinuationUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:37 AM
MET WITH:Teofil AntonTIME VISIT/
INSPECTION COMPLETED:
01:05 PM
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On 8/29/2024, Licensing Program Analyst (LPA) Cassie Yang arrived unannounced at the facility to conduct an annual continuation visit from annual inspection conducted on 7/11/2024. LPA met with Administrator and explained the purpose of the visit.

Today's census is five residents in care with no residents on hospice services.

During today's visit, LPA conducted a file review of three staff records and five residents records.

LPA completed the CARE tool and no deficiencies cited during today's visit.

LPA took a photo copy of facility liability insurance.

Exit interview and a copy of the report will be emailed to Administrator.
SUPERVISORS NAME: Anthony Perez
LICENSING EVALUATOR NAME: Cassie Yang
LICENSING EVALUATOR SIGNATURE: DATE: 08/29/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/29/2024
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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