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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 486803614
Report Date: 06/06/2023
Date Signed: 06/06/2023 01:57:28 PM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
This is an official report of an unannounced visit/investigation of a complaint received in our office on
05/10/2023 and conducted by Evaluator David Leibert
COMPLAINT CONTROL NUMBER: 21-AS-20230510081951
FACILITY NAME:OAKWOOD MEMORY & SENIOR CAREFACILITY NUMBER:
486803614
ADMINISTRATOR:MAHAWAR, RASHMIKAFACILITY TYPE:
740
ADDRESS:1025 OAKWOOD AVENUETELEPHONE:
(707) 643-0473
CITY:VALLEJOSTATE: CAZIP CODE:
94591
CAPACITY:30CENSUS: 17DATE:
06/06/2023
UNANNOUNCEDTIME BEGAN:
01:45 PM
MET WITH:TJ IlaganTIME COMPLETED:
02:15 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Medications - medication is not dispensed per physicians orders
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Licensing Program Analyst Leibert arrived unannounced for the purpose of delivering findings on this complaint. LPA met with TJ Ilagan and discussed the allegation and findings. During the course of this investigation, this Department has interviewed witnesses and obtained and reviewed documents, as well as made site visits to the facility. The following determinations are made: R1 was placed at the facility on 3/23/23 from a medical facility; 4 new medications were sent with R1 to the placement; medications previously ordered for R1 were not sent to facility; Facility staff state that both the medical facility and the Responsible Person for R1 were contacted more than once in attempts to obtain the medications for R1; R1 was not administered the previously ordered medication; A Home Health Nurse was ordered to obtain and manage the medications for R1; The order for the Home Health Nurse expired due to a mis-communication by the medical facility and the issue of the prior medication was not addressed. Although the allegation may be true, based on statements and documents, there is not a preponderance of evidence to prove the allegation true or, not true. Therefore, the allegation is UNSUBSTANTIATED.
Report Left.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Carla Martinez
LICENSING EVALUATOR NAME: David Leibert
LICENSING EVALUATOR SIGNATURE:

DATE: 06/06/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/06/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
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