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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486803614
Report Date: 08/10/2026
Date Signed: 08/10/2026 05:35:14 PM

Document Has Been Signed on 08/10/2026 05:35 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
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME:OAKWOOD MEMORY & SENIOR CAREFACILITY NUMBER:
486803614
ADMINISTRATOR/
DIRECTOR:		REYNALDO GUTIERREZFACILITY TYPE:
740
ADDRESS:1025 OAKWOOD AVENUETELEPHONE:
(707) 643-0473
CITY:VALLEJOSTATE: CAZIP CODE:
94591
CAPACITY: 30CENSUS: 12DATE:
08/10/2026
TYPE OF VISIT:Case Management - Annual ContinuationUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:15 PM
MET WITH:Theresa "TJ" Ilagan, Designated Responsible PartyTIME VISIT/
INSPECTION COMPLETED:
05:45 PM
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At approximately 12:15 PM, Licensing Program Analyst (LPA) Julie Florio arrived unannounced to conduct a Case Management - Annual Continuation inspection and was greeted by staff. Theresa "TJ" Ilagan, Designated Responsible Party (DRP) was contacted by staff via telephone and arrived at approximately 1:00 PM. LPA was informed that Administrator was unable to be present for today's inspection. Facility is a Residential Care Facility for the Elderly (RCFE) with 12 residents in care. Facility serves memory care residents, has a Hospice waiver for 10, and approval for 10 bedridden residents. Facility has a Department approved waiver for a secured perimeter which was granted in 08/2016.

At approximately 12:30 PM, LPA conducted file review of five (5) staff files and observed the following: One (1) of five (5) staff files reviewed was served missing proof of some of the required annual training hours, (see LIC809D). Two (2) of five (5) staff files reviewed were observed missing proof of some of the required annual medication training hours for staff who give medications, (see LIC809D). Five (5) of five (5) staff files reviewed were observed to have the additional required paperwork and proof of current first aid and CPR training certifications.

At approximately 2:15 PM, LPA conducted file review of five (5) resident files and observed the following: Three (3) of five (5) resident files reviewed were observed missing the required current care plan updated and reviewed within the last 12 months, (see LIC809D). One (1) of five (5) resident files reviewed was observed missing a current LIC602A Physician's Report updated within the last 12 months as required for residents with dementia, (see LIC809D).

Continued on LIC809C...
Bethany Moellers
Julie Florio
DATE: 08/10/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/10/2026
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 7
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
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME: OAKWOOD MEMORY & SENIOR CARE
FACILITY NUMBER: 486803614
VISIT DATE: 08/10/2026
NARRATIVE
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Continued from LIC809...

At approximately 3:45 PM, LPA reviewed medications and medication records. LPA observed facility maintaining centrally stored medication records in their computer system and the logs do not reflect all of the required information. LPA observed missing physician directions, separate line entries for each bottle of a medication received in the facility, as well as the name of the prescribing physician. DRP has a copy of the Departments Centrally Store Medication and Destruction log and agrees to use this format going forward to ensure compliance with regulation. The remaining medications and medication records reviewed were observed stored and maintained in compliance with regulation.

If not already submitted since LPA's last visit, updated copies of the following documents are to be submitted to CCL by COB 09/03/2026:
  • LIC500 - Personnel Roster (updated to include administrators schedule)
  • Proof of current liability insurance in the required amounts
  • LIC610E Emergency Disaster Plan (updated)

Deficiencies are being cited from the California Code of Regulations, Title 22, Division 6 of California Regulation and the Health and Safety Code. Failure to correct the deficiencies by the plan of correction date and/or repeat deficiencies within a 12 month period may result in civil penalties.

Exit interview conducted with DRP whose signature on form confirms receipt of documents Appeal rights provided.

NAME OF LICENSING PROGRAM MANAGER: Bethany Moellers
NAME OF LICENSING PROGRAM ANALYST: Julie Florio
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 08/10/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/10/2026
LIC809 (FAS) - (06/04)
Page: 3 of 7
Document Has Been Signed on 08/10/2026 05:35 PM - It Cannot Be Edited


Created By: Julie Florio On 08/10/2026 at 04:23 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: 08/10/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
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 record review, the licensee did not comply with the section cited above in 1 out of 5 staff files reviewed and observed missing some of the required annual training hours which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/11/2026
Plan of Correction
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Licensee to submit proof that Staff 1 (S1) has completed all of the required annual training hours to CCL by POC due date of 09/11/2026.
Type B
Section Cited
HSC
1569.69(a)(2)
Other Provisions
(a) Each residential care facility for the elderly licensed under this chapter shall ensure that each employee of the facility who assists residents with the self-administration of medications meets all of the following training requirements: (2) In facilities licensed to provide care for 15 or fewer persons, the employee shall complete 10 hours of initial training. This training shall consist of 6 hours of hands-on shadowing training, which shall be completed prior to assisting with the self-administration of medications, and 4 hours of other training or instruction, as described in subdivision (f), which shall be completed within the first two weeks of employment.

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 2 out of 5 staff files reviewed and observed missing proof of completion for some of the required annual training hours which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/11/2026
Plan of Correction
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Licensee to submit proof that Staff 1 (S1) and Staff 3 (S3) have completed all of the required annual medication training hours to CCL by POC due date of 09/11/2026.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Bethany Moellers
NAME OF LICENSING PROGRAM MANAGER:
Julie Florio
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 08/10/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/10/2026


LIC809 (FAS) - (06/04)
Page: 4 of 7
Document Has Been Signed on 08/10/2026 05:35 PM - It Cannot Be Edited


Created By: Julie Florio On 08/10/2026 at 04:23 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: 08/10/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87463(h)
Reappraisals
(h) The licensee shall request that all residents receive an annual routine visit with a licensed medical professional once every twelve months, either in person or by video appointment.

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 1 out of 5 resident files reviewed and observed missing a current physician's report within the last 12 months which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/11/2026
Plan of Correction
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Licensee to submit proof of a current physician's report for Resident 2 (R2) to the CCL by POC due date of 09/11/2026.
Type B
Section Cited
CCR
87463(i)
Reappraisals
(i) When there is significant change in condition, as defined in Section 87101, Definitions, or once every 12 months, whichever occurs first, the licensee shall arrange an in-person or virtual meeting or conference call to share the reappraisal with the resident, the resident's representative, if applicable, and appropriate facility staff, as specified in Section 87467, Resident Participation in Decision Making.

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 and observed missing a current care plan updated and reviewed within the last 12 months which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/11/2026
Plan of Correction
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Licensee to submit updated care plans for Residents 2, 3, and 5 (R2, R3, and R5) to CCL by POC due date of 09/11/2026.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Bethany Moellers
NAME OF LICENSING PROGRAM MANAGER:
Julie Florio
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 08/10/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/10/2026


LIC809 (FAS) - (06/04)
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