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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 397002695
Report Date: 11/09/2021
Date Signed: 11/09/2021 04:52:44 PM

Document Has Been Signed on 11/09/2021 04:52 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, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
FACILITY NAME:OASIS GUEST HOMEFACILITY NUMBER:
397002695
ADMINISTRATOR:BRANDON ROSEFACILITY TYPE:
740
ADDRESS:9207 MAMMATH PEAK CIRCLETELEPHONE:
(209) 565-5472
CITY:STOCKTONSTATE: CAZIP CODE:
95212
CAPACITY: 5CENSUS: 5DATE:
11/09/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:16 PM
MET WITH:Brandon RoseTIME COMPLETED:
05:05 PM
NARRATIVE
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On 11/9/21 at 1:16pm, Licensing Program Analyst (LPA) Michael Bilger arrived at this facility unannounced to conduct an annual inspection visit. LPA met with the administrator Brandon Rose and explained the purpose of the visit.

LPA Bilger inspected the physical plant including but not limited to the kitchen, dining room, resident bedrooms; resident bathrooms, laundry room, living area, common TV area, and outside backyard of the facility to ensure compliance with Title 22 regulations. Facility is a 5 bed facility with a current census of 5. LPA also conducted the infection control domain tool.
The facility has an approved COVID Mitigation plan LIC 808 form in place.The facility has central entry point and has implemented screening and sign in procedures at the front door area. The facility conducts routine symptom screening for employees, residents, and visitors. LPA observed the facility to have hand washing, COVID - 19 informational, and social distancing signs posted throughout the facility, on the front door, and outside including entry way. The facility has a designated infection control lead. The facility is able to designate and dedicated a Covid-19 room/bathroom if needed. Common touch surfaces are cleaned after each use.

Water temperature reads 110.1*F in the bathroom and room temperature reads 77*F. LPA observed the facility to have adequate food supply. Resident rooms were sanitary and had the required furniture and furnishings. The facility common areas were clean and furnished. Smoke and carbon detectors were in good repair. Fire extinguisher was checked 11/20/2020. Facility has an emergency food and water kit. Administrator certificate expires 6/4/2022. Sharp objects were noted to be accessible to residents in care during LPAs visit.

{Cont. on LIC 809C}
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Michael Bilger
LICENSING EVALUATOR SIGNATURE: DATE: 11/09/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/09/2021
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
FACILITY NAME: OASIS GUEST HOME
FACILITY NUMBER: 397002695
VISIT DATE: 11/09/2021
NARRATIVE
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Resident medications observed to be accessible to residents in care. Physician's report and appraisal needs and service plans were not updated in 3 of 5 resident records reviewed. Four staff records were reviewed. All staff first aid and required training is updated. All staff fingerprints cleared.

Per California Code of Regulations, Title 22, deficiencies were observed during this visit as noted on LIC 809D. Exit interview was held with Brandon Rose and a report along with appeal rights was given to Administrator Brandon Rose
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Michael Bilger
LICENSING EVALUATOR SIGNATURE:

DATE: 11/09/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/09/2021
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 11/09/2021 04:52 PM - It Cannot Be Edited


Created By: Michael Bilger On 11/09/2021 at 04:02 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
, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

FACILITY NAME: OASIS GUEST HOME
FACILITY NUMBER: 397002695

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/09/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87309(a)
Storage Space
(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:
Deficient Practice Statement
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Based on observation the licensee did not comply with the section cited above. LPA observed a shovel and power hedge trimmer acessible to residents in care which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 11/10/2021
Plan of Correction
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Licensee secured items to a locked area and ensured inacessiblity to residents in care during LPA visit.

Licensee will develop a plan to secure all dangerous items and ensure they are inaccessible to residents in care. Licensee to submit plan to LPA by POC due date.

Type A
Section Cited
CCR
87465(h)(2)
Incidental Medical and Dental Care Services
(h) The following requirements shall apply to medications which are centrally stored: (2) Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation the licensee did not comply with the section cited above. LPA observed medication stored in refrigerator and accessible to residents in care which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 11/10/2021
Plan of Correction
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Licensee to develop a plan to have all medications appropriately secured and inaccessible to residents in care and submit plan to LPA by POC due date.
Licensee to conduct staff training on regulation 87465(h)(2) and submit proof of scheduled training date to LPA by POC due date.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Liza King
LICENSING EVALUATOR NAME:Michael Bilger
LICENSING EVALUATOR SIGNATURE:
DATE: 11/09/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/09/2021


LIC809 (FAS) - (06/04)
Page: 3 of 5
Document Has Been Signed on 11/09/2021 04:52 PM - It Cannot Be Edited


Created By: Michael Bilger On 11/09/2021 at 04:02 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
, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

FACILITY NAME: OASIS GUEST HOME
FACILITY NUMBER: 397002695

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/09/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87705(c)(5)
Care of Persons with Dementia
(c) Licensees who accept and retain residents with dementia shall be responsible for ensuring the following: (5) Each resident with dementia shall have an annual medical assessment as specified in Section 87458, Medical Assessment, and a reappraisal done at least annually, both of which shall include a reassessment of the resident's dementia care needs.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in 3 out of 5 resident records reviewed. Physician reports and appraisals were not updated, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/19/2021
Plan of Correction
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Licensee will complete physician reports and appraisals for R2, R3, and R5 and submit copies to LPA by POC due date.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Liza King
LICENSING EVALUATOR NAME:Michael Bilger
LICENSING EVALUATOR SIGNATURE:
DATE: 11/09/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/09/2021


LIC809 (FAS) - (06/04)
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