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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496801362
Report Date: 12/06/2021
Date Signed: 12/06/2021 12:31:53 PM

Document Has Been Signed on 12/06/2021 12:31 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, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928
FACILITY NAME:OAK TREE LODGEFACILITY NUMBER:
496801362
ADMINISTRATOR:JOHNSON, PAMELAFACILITY TYPE:
740
ADDRESS:6360 OLD REDWOOD HWY.TELEPHONE:
(707) 836-7777
CITY:SANTA ROSASTATE: CAZIP CODE:
95403
CAPACITY: 6CENSUS: 6DATE:
12/06/2021
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
11:30 AM
MET WITH:Sam Ambrecht-Lead CaregiverTIME COMPLETED:
12:40 PM
NARRATIVE
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Licensing Program Analyst (LPA) Alviso, conducted a Case Management Incident Inspection on 12/6/21 at approximately 11:30, and met with Sam Ambrecht lead caregiver/Administrator Assistant. LPA was screened for covid symptoms, and temperature was taken, before LPA was allowed to stay in the facility. LPA advised facility staff to use a covid symptoms questionnaire of some kind such as the CDC's covid symptom questions to be asked of each person, individual, staff, and residents, entering the facility. Sam Ambrecht, caregiver printed out copies of the form from the CDC website and immediately put them out on the screening table to be used.

LPA reviewed resident incident, and discussed the incident with staff. LPA met with the resident in care. LPA has received documentation and information from the administration staff regarding the incident and all follow-up. Administration staff addressed the incident, notified all required party(s), and completed required reporting. Administration staff will keep Licensing updated as needed and required. Administration staff will ensure the resident's current needs are met; Administration staff will ensure that the facility can meet all resident's care needs.

No deficiencies cited today.
SUPERVISORS NAME: Hope DeBenedetti
LICENSING EVALUATOR NAME: Dina Alviso
LICENSING EVALUATOR SIGNATURE: DATE: 12/06/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/06/2021
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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