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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496800208
Report Date: 08/27/2024
Date Signed: 08/27/2024 02:31:16 PM

Document Has Been Signed on 08/27/2024 02:31 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, 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: 6DATE:
08/27/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:20 AM
MET WITH:Krystal Boyles-Ambrecht (staff)TIME VISIT/
INSPECTION COMPLETED:
02:46 PM
NARRATIVE
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Licensing Program Analyst (LPA) Cuadra arrived unannounced to conduct an Annual Required inspection and met with staff Krystal Boyles-Ambrecht. The annual fees are current. There are residents with a diagnosis of dementia and no residents receiving hospice services. Required postings were observed.

LPA/staff initiated a tour of the facility at approximately 11:30 am and observed the following: Facility was a comfortable temperature and passageways were free from obstructions. Facility has a pool that is surrounded by a locked gate to ensure resident safety. Resident rooms were furnished per regulation. Extra linens and hygiene products were available. Water temperature in resident's bathrooms measured at 101.3, 103.1 and 101.8 degrees F in bathrooms used by residents in care, which are not within the range allowed by regulation. Toxins were inspected and are stored in the locked laundry room. At least two days of perishable and one week of nonperishable food was available. Fire extinguishers were last inspected May, 2024. Smoke alarms throughout the facility and carbon monoxide detector were tested and operational. Auditory alarms are operational. Last disaster drill conducted on 5/16/2024. Medications in a locked cabinet in the kitchen.

At approximate 11:45 am LPA/staff observed that toilet located in bathroom #2 was not properly flushing. Also, upon entering to bathroom #3 located in the hallway, LPA/staff smelled a strong odor and it was apparently due to bathroom does not have adequate ventilation.

Continue on LIC809C...
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Marisol Cuadra
LICENSING EVALUATOR SIGNATURE: DATE: 08/27/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/27/2024
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 08/27/2024 02:31 PM - It Cannot Be Edited


Created By: Marisol Cuadra On 08/27/2024 at 01:26 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: OAK TREE RANCH
FACILITY NUMBER: 496800208

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/27/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87303(a)
Maintenance and Operation
The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA/staff observation toilet located in bathroom #2 was not properly flushing. Also, upon entering to bathroom #3 located in the hallway, LPA/staff smelled a strong odor and it was apparently due to bathroom does not have adequate ventilation, the licensee did not comply with the section cited above in two bathrooms used by residents in care, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 08/28/2024
Plan of Correction
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Licensee/Administrator will send a written plan regarding how the facility plans to address the repairs in a timely manner and they will follow up with proof of repairs of the toilet located in bathroom #2 and installation of ventilation in bathroom #3 by not later than 9/3/24.
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:Bethany Moellers
LICENSING EVALUATOR NAME:Marisol Cuadra
LICENSING EVALUATOR SIGNATURE:
DATE: 08/27/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/27/2024


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 08/27/2024 02:31 PM - It Cannot Be Edited


Created By: Marisol Cuadra On 08/27/2024 at 01:26 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: OAK TREE RANCH
FACILITY NUMBER: 496800208

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/27/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87303(e)(2)
Maintenance and Operation
(e) Water supplies and plumbing fixtures shall be maintained as follows: (2) Faucets used by residents for personal care such as shaving and grooming shall deliver hot water. Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degree F (41 degrees C) and not more than 120 degree F (49 degrees C).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA's/staff observation, interview and record review, the licensee did not comply with the section cited above in three out of three faucets used by residents, water measured at 101.3, 103.1 and 101.8 degrees F, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/03/2024
Plan of Correction
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Licensee/Administrator to ensure the hot water is monitored between 105 and 120.degrees Fahrenheit. Monitor the hot water for a period of one week (7 days). Submit a copy of the hot water log, and a plan on how the facility will ensure the hot water is maintained in compliance with regulation. Submit plan of correction by 9/3/24, and follow up with copy of hot water log and maintenance plan by 9/3/24.
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:Bethany Moellers
LICENSING EVALUATOR NAME:Marisol Cuadra
LICENSING EVALUATOR SIGNATURE:
DATE: 08/27/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/27/2024


LIC809 (FAS) - (06/04)
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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
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME: OAK TREE RANCH
FACILITY NUMBER: 496800208
VISIT DATE: 08/27/2024
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Continued from LIC809...

LPA initiated file review at 12:00pm. Two staff and six resident files were reviewed. Staff First Aid/CPR Certificates are current and additional training hours are complete. One out of six resident's medical assessment needs to be current, care plans for all residents were updated. Administrator Certificate for Pamela Johnson 7005563740 is showing as pending in the Department's list of renewal of administrator's certificate. Medication and medication records were reviewed.

Administrator submitted updates for the following documents: LIC500- Personnel Report, LIC308- Designation of Administrative Responsibility and Liability Insurance.

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: 08/27/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/27/2024
LIC809 (FAS) - (06/04)
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