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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 397002695
Report Date: 02/14/2022
Date Signed: 02/14/2022 03:33:07 PM

Document Has Been Signed on 02/14/2022 03:33 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
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:
02/14/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Brandon Rose, AdministratorTIME COMPLETED:
03:45 PM
NARRATIVE
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 On 2/14/22 at 9:30am Licensing Program Analyst (LPA) Kevin Gould arrived at Oasis Guest Home for the purpose of conducting a required 1 year annual inspection. LPA met with Administrator, Brandon Rose and together conducted a tour of the home.

LPA and Administrator evaluated the physical plant to ensure the health and safety of the residents in care. Areas inspected are including but not limited to the kitchen, resident bedrooms; resident bathrooms, living and dining room and outdoor areas. LPA observed the facility to be free of odor, clean and in good repair. LPA observed that all rooms are equipped with the required furniture and sufficient lighting throughout the facility.

LPA measured the water temperature, temperature measured at 110 degrees F which meets the 105-120 degree Fahrenheit regulation. LPA observed sufficient seven day non-perishable and two day perishable food supplies. Fire extinguishers and smoke detectors are current and in compliance with fire safety. LPA notes the facility had the required carbon monoxide detectors. First aid kit was checked and is complete. LPA observed centrally stored medications secure from residents.

LPA Gould reviewed five staff files and four residents files. LPA Gould observed 1 staff with an expired first aid certificate. LPA Gould observed three staff with missing Health Screening Reports (LIC 503). LPA observed no staff annual training for 2021 including no annual training for providing services to residents with dementia.

Per California Code of Regulations, Title 22 the following deficiencies were cited during today's inspection. An exit interview was conducted, and a copy of this report and appeal rights were left at the facility.
SUPERVISORS NAME: Czarrina A Camilon-Lee
LICENSING EVALUATOR NAME: Kevin Gould
LICENSING EVALUATOR SIGNATURE: DATE: 02/14/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/14/2022
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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Document Has Been Signed on 02/14/2022 03:33 PM - It Cannot Be Edited


Created By: Kevin Gould On 02/14/2022 at 02:52 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: 02/14/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87411(c)(1)
Personnel Requirements - General
(1) Staff providing care shall receive appropriate training in first aid from persons qualified by such agencies as the American Red Cross.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA's review of staff files, the licensee did not comply with the section cited above in 1 out of 5 staff records reviewed did not have a current first aid certificate which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 02/15/2022
Plan of Correction
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facility will send documentation of staff enrolled in CPR/First Aid training to LPA by the 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:Czarrina A Camilon-Lee
LICENSING EVALUATOR NAME:Kevin Gould
LICENSING EVALUATOR SIGNATURE:
DATE: 02/14/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/14/2022


LIC809 (FAS) - (06/04)
Page: 2 of 3
Document Has Been Signed on 02/14/2022 03:33 PM - It Cannot Be Edited


Created By: Kevin Gould On 02/14/2022 at 02:52 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: 02/14/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87412(a)(11)
Personnel Records
(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information: (11) A health screening as specified in Section 87411, Personnel Requirements - General.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA's review of staff records, the licensee did not comply with the section cited above in 3 out of 5 staff files reviewed which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 02/28/2022
Plan of Correction
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Licensee will ensure all health screening documents are filled out by staff and retained in the facility records by the POC due date. Facility will also provide a written plan detailing how the facility will ensure the violation does not reoccur.
Type B
Section Cited
HSC
1569.625(b)(2)
Other Provisions
(2) In addition to paragraph (1), training requirements shall also include an additional 20 hours annually, eight hours of which shall be dementia care training, as required by subdivision (a) of Section 1569.626, and four hours of which shall be specific to postural supports, restricted health conditions, and hospice care, as required by subdivision (a) of Section 1569.696. This training shall be administered on the job, or in a classroom setting, or both, and may include online training.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA's review of staff records, the licensee did not comply with the section cited above as all staff reviewed did not receive the required training hours for facilities caring for individuals with dementia which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 02/28/2022
Plan of Correction
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Licensee will ensure all staff are enrolled in a training program for staff to meet the needs of dementia training By the POC due date. Facility will also provide a written plan detailing how the facility will ensure the violation does not reoccur.
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:Czarrina A Camilon-Lee
LICENSING EVALUATOR NAME:Kevin Gould
LICENSING EVALUATOR SIGNATURE:
DATE: 02/14/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/14/2022


LIC809 (FAS) - (06/04)
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