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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496800208
Report Date: 04/09/2024
Date Signed: 04/09/2024 09:55:51 AM

Document Has Been Signed on 04/09/2024 09:55 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
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME:OAK TREE RANCHFACILITY NUMBER:
496800208
ADMINISTRATOR/
DIRECTOR:		JOHNSON, PAMELAFACILITY TYPE:
740
ADDRESS:1482 OLIVET ROADTELEPHONE:
(707) 571-1122
CITY:SANTA ROSASTATE: CAZIP CODE:
95401
CAPACITY: 6CENSUS: 4DATE:
04/09/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:52 AM
MET WITH:Claudia Patricia Magana (Staff)TIME VISIT/
INSPECTION COMPLETED:
10:10 AM
NARRATIVE
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Licensing Program Analyst (LPA) Cuadra arrived unannounced to conduct a Case Management - Incident visit, and met with Claudia Patricia Magana (Staff). Administrator, Pamela Johnson was not able to come, but was available by phone and gave authorization to staff to sign the report.

The purpose of this Case Management Visit is to follow up on another agency report submitted to Community Care Licensing (CCL) on 4/3/24. Based on police records #SD240880063 obtained by LPA, on 3/28/24 at approximate 1:01pm, resident (R1) walked out the facility and was being aggressive to staff (S1) walking down the street and S1 was with R1 at all times.

During today's visit, LPA reviewed R1's care plan and physician report dated 3/9/24 who has a diagnosis of dementia. R1's care plan indicates that R1 needs general supervision due to confusion and wandering. Based on interviews with staff (S1), it was confirmed that they were following R1 at all times to ensure their safety while they were wandering away of the facility. Per Administrator, they were in the facility and attempted to re-direct R1, but R1 wanted to keep walking away from the facility, so they had S1 following them around. However, the facility did not notify CCL regarding the incident. LPA had a discussion with Administrator clarifying when an incident report needs to be submitted to CCL.

Deficiencies cited from the California Code of Regulations, Title 22, Division 6 of California Regulation. Appeal rights given. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties.

Exit interview conducted with staff and a copy of this report was printed for the facility.

SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Marisol Cuadra
LICENSING EVALUATOR SIGNATURE: DATE: 04/09/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/09/2024
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 04/09/2024 09:55 AM - It Cannot Be Edited


Created By: Marisol Cuadra On 04/09/2024 at 09:12 AM
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: OAK TREE RANCH
FACILITY NUMBER: 496800208

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/09/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
04/19/2024
Section Cited
CCR
87211(a)(1)(D)

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87211 Reporting Requirements (a) Each licensee shall furnish to the licensing agency such reports as the Dpt may require…(1) A written report shall be submitted to the licensing agency & person responsible for the resident within 7 days of the occurrence of any of the events…(D) Any incident which threatens the welfare, safety or health of any resident...unexplained absence of any resident. This requirement has not been met as evidence by:
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Administrator to ensure all incidents that threaten the safety of residents are reported to CCL per regulation. Administrator to review regulation, conduct training for all staff on reporting requirements. Signed statement that the regulation was reviewed & sign in sheet for all staff trained to be submitted by POC due date.
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Based on LPA’s records review and interviews conducted with Administrator confirmed that they did not ensure that CCL was notified of incident involving R1 after AWOL, which poses a potential health & safety risk to residents in care.
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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:Bethany Moellers
LICENSING EVALUATOR NAME:Marisol Cuadra
LICENSING EVALUATOR SIGNATURE:
DATE: 04/09/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/09/2024


LIC809 (FAS) - (06/04)
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