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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486803614
Report Date: 08/25/2023
Date Signed: 08/30/2023 08:31:24 AM

Document Has Been Signed on 08/30/2023 08:31 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
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:
08/25/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Theresa Ilagan, ManagerTIME COMPLETED:
08:30 PM
NARRATIVE
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Licensing Program Analyst Carol Fowler, arrived unannounced to conduct a Required Annual Inspection and met with Theresa Ilagan, Manager. The facility was a comfortable temperature, free from obstructions, and was well lit. Extra linens were available and required bath mats and grab bars were observed. Water temperature in resident's bathrooms measured between 105 and 120 degrees F which is within acceptable range. Medications were centrally stored and locked. Residents handle their own cash resources.

Fire extinguishers located in the kitchen and hallways was last inspected 02/15/2023. Smoke alarm system and sprinkler system were last inspected 4/2/2023. The last Disaster Drill was conducted on 8/1/2023. Staff and resident records were reviewed. Administrator Certificate for Rasmika Mahawal, #6029802740 expired March 5, 2022 but has renewed. Staff have required First Aid and CPR certificates. Residents have current Medical Assessments and Appraisals/Care Plans as required by regulation. Medications were reviewed.

Deficiencies LPA observed during tour and record review:
  • Cleaning products and other toxins located in an unlocked supply room
  • Food (meat) not properly stored in freezer, freezer dirty
  • Administrator file not stored at the facility




continue on LIC809C
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Carol Fowler
LICENSING EVALUATOR SIGNATURE: DATE: 08/25/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/25/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 6
Document Has Been Signed on 08/30/2023 08:31 AM - It Cannot Be Edited


Created By: Carol Fowler On 08/25/2023 at 06:15 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
, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: OAKWOOD MEMORY & SENIOR CARE
FACILITY NUMBER: 486803614

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/25/2023

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 by having a storage closet unlocked wht cleaning solutions, disinfectants and other toxins accessible which poses an immediate health and safety risk to persons in care.
POC Due Date: 08/26/2023
Plan of Correction
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Manager had staff change the batteries for the lock during the visit. Deficiency cleared during visit.
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:Kimberley Mota
LICENSING EVALUATOR NAME:Carol Fowler
LICENSING EVALUATOR SIGNATURE:
DATE: 08/25/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/25/2023


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 08/30/2023 08:31 AM - It Cannot Be Edited


Created By: Carol Fowler On 08/25/2023 at 06:15 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
, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: OAKWOOD MEMORY & SENIOR CARE
FACILITY NUMBER: 486803614

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/25/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87303(e)(6)
Maintenance and Operation
(e) Water supplies and plumbing fixtures shall be maintained as follows: (6) Toilet, handwashing and bathing facilities shall be maintained in operating condition. Additional equipment shall be provided in facilities accommodating physically handicapped and/or nonambulatory residents, based on the residents' needs.

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 by having a leaking toilet and sink in the common area restroom not maintained in working order which poses a potential health and safety risk to persons in care.
POC Due Date: 09/01/2023
Plan of Correction
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Manager/Administrator agreed to have the toilet and sink repaired and provide CCL with a copy of the invoice no later than the POC date.
Type B
Section Cited
CCR
87412(a)
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:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and record review, the licensee did not comply with the section cited above by not having the Administrators personnel record not at the facility which poses a potential health and safety risk to persons in care.
POC Due Date: 09/01/2023
Plan of Correction
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Manager/Administrator agreed to maintaine a copy of the Administrator personnel record at the facility. Manager/Administrator agreed to read the regulation and submit self certification to CCL no later than the POC 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:Kimberley Mota
LICENSING EVALUATOR NAME:Carol Fowler
LICENSING EVALUATOR SIGNATURE:
DATE: 08/25/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/25/2023


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 08/30/2023 08:31 AM - It Cannot Be Edited


Created By: Carol Fowler On 08/25/2023 at 06:15 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
, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: OAKWOOD MEMORY & SENIOR CARE
FACILITY NUMBER: 486803614

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/25/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87555(b)(8)
General Food Service Requirements
(b) The following food service requirements shall apply: (8) All food shall be of good quality. Commercial foods shall be approved by appropriate federal, state and local authorities. Food in damaged containers shall not be accepted, used or retained.

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 by improperly storing food (meat chicken and ground beef) in a dirty freezer which poses health and safety risk to persons in care.
POC Due Date: 09/01/2023
Plan of Correction
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Manager/Administrator agreed to dispose of all food (meat, chicken and ground beef) improperly stored in the freezer. Clean the freezer. Manager/Administrator will conduct in-service for the facility cooks and provide CCL with a copy of the in-service attendance sheet, receipt of new meat purchased and photos of the clean freezer and packaged meat chicken and ground beef no later than the POC 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:Kimberley Mota
LICENSING EVALUATOR NAME:Carol Fowler
LICENSING EVALUATOR SIGNATURE:
DATE: 08/25/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/25/2023


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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
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME: OAKWOOD MEMORY & SENIOR CARE
FACILITY NUMBER: 486803614
VISIT DATE: 08/25/2023
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continue from LIC809

LPA conducted staff and resident interviews.

LPA requested the following documents to update facility file:

· Designation of Facility Responsibility (LIC 308)
· Control of Property
· Emergency Disaster Plan (LIC 610D)
· Health Screening Report for Administrator (LIC 503)
· Updated Personnel Report (LIC 500)
· Updated Liability Insurance
· Active and Current Administrator Certificate

Facility Documents to be submitted to Community Care Licensing (CCL) by due date of Monday 9/5/2023.


Deficiencies cited from the California Code of Regulations, Title 22, Division 6 of California Regulation. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties. Copy of this report and appeal rights were provided.
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Carol Fowler
LICENSING EVALUATOR SIGNATURE:

DATE: 08/25/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/25/2023
LIC809 (FAS) - (06/04)
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