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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 392700475
Report Date: 01/28/2026
Date Signed: 01/28/2026 02:41:43 PM


COMPREHENSIVE INSPECTION

Document Has Been Signed on 01/28/2026 02:41 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 SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME:OAKS AT INGLEWOOD ASSISTED LIVING, THEFACILITY NUMBER:
392700475
ADMINISTRATOR/
DIRECTOR:		THA CHAYFACILITY TYPE:
740
ADDRESS:6725 INGLEWOOD AVETELEPHONE:
(209) 957-6257
CITY:STOCKTONSTATE: CAZIP CODE:
95207
CAPACITY: 86CENSUS: 70DATE:
01/28/2026
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:07 AM
MET WITH:T. ChayTIME VISIT/
INSPECTION COMPLETED:
03:00 PM
NARRATIVE
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Licensing Program Analyst (LPA) Albert Johnson arrived unannounced to conduct an Annual Inspection.

The facility is a two story structure located in North Stockton with a capacity to serve 86 resident and a current census of 70. The grounds were observed to be maintained and clear of obstruction and debris. There is pond on the premises that was observed to be gated, locked and in compliance with Title 22 regulations. There is sufficient outdoor furniture for the residents to participate in outdoor activities and pergolas for shade. LPA and Staff inspected the physical plant at to ensure the health and safety of the clients in care. LPA inspected the facility with Staff including but not limited to the kitchen area, resident rooms, bathrooms, dining room, and storage areas. The facility had the required carbon monoxide detectors.

LPA observed the facility to be free of odor and clean. LPA observed sufficient lighting throughout the facility. Fire extinguishers and smoke detectors are current and in compliance with fire safety. LPA reviewed fifteen (10) client files and ten (8) staff files, including criminal record clearances.
continued.
NAME OF LICENSING PROGRAM MANAGER: Lisa Rios
NAME OF LICENSING PROGRAM ANALYST: Albert Johnson
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 01/28/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/28/2026
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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California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME: OAKS AT INGLEWOOD ASSISTED LIVING, THE
FACILITY NUMBER: 392700475
VISIT DATE: 01/28/2026
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During the resident file review LPA observed 3 of 10 residents with a diagnosis of Dementia. The facility is not operating in accordance with the terms specified in the plan of operation approved by the department. The facility does not have an approved plan to care for Dementia diagnosed residents.

LPA observed centrally stored medications locked in then medication room. LPA reviewed and compared resident medication vs. resident medication logs. LPA reviewed resident and staff files, and interviewed both. During the inspection LPA observed unlocked toxin in the activities room under the sink accessible to the residents.

All staff were cleared and associated to the facility. First aid kit was checked and is complete. Citations given. Exit interview conducted. A copy of this report was left with the Staff.
NAME OF LICENSING PROGRAM MANAGER: Lisa Rios
NAME OF LICENSING PROGRAM ANALYST: Albert Johnson
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 01/28/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/28/2026
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 01/28/2026 02:41 PM - It Cannot Be Edited


Created By: Albert Johnson On 01/28/2026 at 01:34 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: OAKS AT INGLEWOOD ASSISTED LIVING, THE
FACILITY NUMBER: 392700475

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/28/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
01/29/2026
Section Cited
CCR
87309(a)

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(a) Disinfectants, cleaning solutions, poisons, firearms and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients.

This requirement is not met as evidenced by:
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Staff was able to remove the items during the visit. The facility will have an in-service to address the need to secure toxins and send a copy of the sign-in sheet to the department by the POC date.
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based on observation the licensee failed to secure toxins. A cabinet under the sink in the resident's activity room was left unlocked and it contained toxins. This poses an immediate health and safety risk to residents in care.
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Type A
01/29/2026
Section Cited
CCR87208(a)(5)(6)

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(a) The licensee shall have and maintain a current, written definitive plan of operation for the facility. The licensee shall operate the facility in accordance with the terms specified in the plan of operation and may be cited for not doing so pursuant to Health and Safety Code section 1569.49. The plan and related materials shall be on file in the facility and shall be submitted to the licensing agency with the license application. Any significant changes in the plan of operation which would affect the services to residents shall be submitted to the licensing agency for approval. The plan and related materials shall contain the following:
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The facility will update the plan of operations to include care and supervison of resident with Dementia.
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(5) Staffing plan, qualifications and duties.

(6) Plan for training staff, as required by Health and Safety Code sections 1569.625, 1569.626, and 1569.69 and as specified in Section 87411, Personnel Requirements–General and Section 87705, Care of Persons with Dementia.
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This plan will be submitted to the department for approval. If additional time is need the facility will request additional time to complete the POC.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Lisa Rios
NAME OF LICENSING PROGRAM MANAGER:
Albert Johnson
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 01/28/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/28/2026


LIC809 (FAS) - (06/04)
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