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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496801362
Report Date: 08/17/2022
Date Signed: 08/17/2022 02:22:11 PM

Document Has Been Signed on 08/17/2022 02:22 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 LODGEFACILITY NUMBER:
496801362
ADMINISTRATOR:JOHNSON, PAMELAFACILITY TYPE:
740
ADDRESS:6360 OLD REDWOOD HWY.TELEPHONE:
7078367777
CITY:SANTA ROSASTATE: CAZIP CODE:
95403
CAPACITY: 6CENSUS: 6DATE:
08/17/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Sam Ambrecht-Lead CaregiverTIME COMPLETED:
02:20 PM
NARRATIVE
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Licensing Program Analyst (LPA) Alviso, arrived unannounced to conduct an Required-1 Year inspection and met with Sandra Ambrecht, lead caregiver/back-up to the Administrator. This inspection is focused on the Infection Control procedures and practices of the facility.

Facility has an approved dementia plan of operation. There is an approved hospice waiver for one(1) resident. The new updated Infection Control Plan was recently submitted as required by the Department. Fire clearance is approved for six (6) non-ambulatory. There were six (6) residents in care at the facility during the inspection. Residents are screened daily, and observed for any changes, all information is logged. Facility was found to be at a comfortable temperature for the residents in care. LPA observed all exits free from obstruction. Toxins are stored in locked cabinets. There was a sufficient supply of hygiene products, cleaners, and paper products for use as needed. Medications were stored locked making them inaccessible to residents in care. All exit alarms were on exit doors and working properly. All bathrooms had grab bars, and non-slip mat/flooring for bathing as needed. All postings were up and visible to all as required. Facility has a sufficient supply of personal protective equipment(PPE) for use by staff and others, residents and/or visitors as needed or wanted. Staff Sam was observed wearing a mask, as required, upon LPA's entry into the facility.

LPA observed the following during the inspection: Staff didn't screen the LPA upon entry and/or at any time ask to screen the LPA. The LPA discussed the screening requirements with staff Sam. This deficiency will be cited, Administrator Qualifications and Duties 87405(d)(2)-see LIC809D.

Continued on page LIC809C..
SUPERVISORS NAME: Hope DeBenedetti
LICENSING EVALUATOR NAME: Dina Alviso
LICENSING EVALUATOR SIGNATURE: DATE: 08/17/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/17/2022
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 5
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 LODGE
FACILITY NUMBER: 496801362
VISIT DATE: 08/17/2022
NARRATIVE
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LPA observed a large pair of scissors in a resident's room (R1), and observed three pairs of small scissors and a metal sharp pointed mail opener in another resident's room (R2); These items pose a danger and risk for residents in care, this deficiency will be cited, Care Of Persons With Dementia 87705(f)(1).
LPA observed a residents room to smell strongly of urine: LPA observed that the residents bathroom also smelled strongly of urine. The LPA observed that the rug in front of the residents bed showed that there were many stains; Staff stated to the LPA they didn't notice the stains. LPA asked if the rug in the residents room is cleaned on a regular basis, and the incontinent resident's bed wiped down as needed as staff stated to the LPA that the resident was changed and is clean and dry. The staff stated to the LPA the rug was cleaned a about a month ago, and the resident's bedding is washed as needed. LPA stated that part of caring for incontinent residents is to also ensure that the facility remains free of urine odors. Deficiency cited, 87625(b)(3) Managed Incontinence.
LPA observed two(2) facility fans that had very dirty fan blades with lots of dust accumalated-both fans were running. LPA obtained pictures. The staff turned both the fans off and acknowledged to the LPA that the fans were dirty and needed to be cleaned. This deficiency will be cited, Maintenance and Operation 87303(a). All deficiencies cited are found on LIC809D pages.

Licensee to submit by 8/31/22 the following updated forms:
LIC308 - Designation of Administrator Responsibility
LIC500 - Updated Personnel Report
LIC610 - Updated Emergency Disaster Plan,
Copy of Current Lease Agreement(if home leased to the Licensee)
Copy of Current Liability Insurance
Copy of current Administrator Certificate
Copy of updated Disaster/Emergency Evacuation plan.

Deficiencies cited from the California Code of Regulations, Title 22, Division 6 and/or Health & Safety Code Deficiencies not corrected within specified time frame and/or repeat violations within 12 months, may result in civil penalties being assessed. Exit interview conducted with staff Sam Ambrecht. Appeal rights provided for the Administrator.
SUPERVISORS NAME: Hope DeBenedetti
LICENSING EVALUATOR NAME: Dina Alviso
LICENSING EVALUATOR SIGNATURE:

DATE: 08/17/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/17/2022
LIC809 (FAS) - (06/04)
Page: 2 of 5
Document Has Been Signed on 08/17/2022 02:22 PM - It Cannot Be Edited


Created By: Dina Alviso On 08/17/2022 at 01:07 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 LODGE
FACILITY NUMBER: 496801362

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/17/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87705(d)(2)
Administrator Qualifications and Duties- 87405(d)(2) The administrator shall have the qualifications specified in Sections 87405(d)(1) through (7). If the licensee is also the administrator, all requirements for an administrator shall apply: (2) Knowledge of and ability to conform to the applicable laws, rules and regulations.
This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA's observation the licensee did not comply with the section cited above, the LPA was not screened as required which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 08/18/2022
Plan of Correction
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Licensee to ensure that all Visitors & Staff are screened as required before entering and/or being allowed in the facility. Submit how the facility will be in compliance and ensure that all visitors and staff are screened as required, helping ensure health and safety of residents in care and being in compliance with regulation requirements. POC due 8/18/22
Type A
Section Cited
CCR
87705(F)(1)

Care of Persons with Dementia 87705(f)(1) The following shall be stored inaccessible to residents with dementia:(1)Knives, matches, firearms, tools and other items that could constitute a danger to the resident(s).
This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA's observation the licensee did not comply with the section cited above as the LPA observed a resident's room(R1) to have a large pair of scissors, and another resident's room (R2) to have three small scissors and a sharp metal letter opener which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 08/18/2022
Plan of Correction
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Licensee to ensure that the facility secures any items that maypose a risk to the health and safety of residents in care are locked up/inaccessible to residents in care as required by regulation. Submit how the facility will ensure compliance with this regulation, and inservice with all staff regarding the plan of correction and compliance with regulation. POC due 8/18/22.
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:Hope DeBenedetti
LICENSING EVALUATOR NAME:Dina Alviso
LICENSING EVALUATOR SIGNATURE:
DATE: 08/17/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/17/2022


LIC809 (FAS) - (06/04)
Page: 3 of 5
Document Has Been Signed on 08/17/2022 02:22 PM - It Cannot Be Edited


Created By: Dina Alviso On 08/17/2022 at 01:43 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 LODGE
FACILITY NUMBER: 496801362

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/17/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87203

87203 Fire Safety
All facilities shall be maintained in conformity with the regulations adopted by the State Fire Marshal for the protection of life and property against fire and panic.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA's observation the licensee did not comply with the section cited above as the LPA observed the fire extinguisher to not have been serviced and tagged as required, the tag was expired as of 8/9/22. which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/26/2022
Plan of Correction
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Licensee to ensure that all fire extinguishers are annually serviced as required. Licensee will sibmit proof of extinguishers having been serviced and brought into compliance and/or receipt showing purchased fire extinguisher(s) that are current/charged to bring the facility into compliance regarding this regulation. Submit plan on what was done to correct the deficiency and plan on ensuring future compliance with this regulation. POC due 8/26/22,
Type B
Section Cited
CCR
87625(b)(3)
Managed Incontinence 87625(b)(3)
(b)In addition to Section 87611, General Requirements for Allowable Health Conditions, the licensee shall be responsible for the following: (3) Ensuring that incontinent residents are kept clean and dry and that the facility remains free of odors from incontinence.

This requirement is not met as evidenced by:Managed Incontinence
Deficient Practice Statement
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Based on LPA's observation during tour with the staff Sam during the inspection; Resident room smelled strongly of urine, the resident's rug in the front of their bed was stained and in need of cleaning, and the bathroom also smelled strongly of urine odor, the licensee did not comply with the section cited above which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/26/2022
Plan of Correction
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Licensee to submit how the resident's room was cleaned, including the rug and bathroom, and submit plan on how the facility will ensure the resident is receiving all incontinent needs met, including keeping the resident room free of strong urine odor as required by regulations. POC due 8/26/22.
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:Hope DeBenedetti
LICENSING EVALUATOR NAME:Dina Alviso
LICENSING EVALUATOR SIGNATURE:
DATE: 08/17/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/17/2022


LIC809 (FAS) - (06/04)
Page: 4 of 5
Document Has Been Signed on 08/17/2022 02:22 PM - It Cannot Be Edited


Created By: Dina Alviso On 08/17/2022 at 01:58 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 LODGE
FACILITY NUMBER: 496801362

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/17/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87303(a)
87303 Maintenance and Operation (a)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's observation, the licensee did not comply with the section cited above as the LPA observed two fans that were on were found to be dirty with lots of dust accumallated on the fans outside protecrive cover and all on the inside on the fan's spinning blades and parts. which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/26/2022
Plan of Correction
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Licensee to ensure the two fans are cleaned before using them in the facility and/or replace the fans if needed. Please submit plan of correction in how the facility ensured the fans used in the home are clean for use to cool the air when needed, as the residents are breathing in the air in the facility. Plan to ensure compliance with regulation. POC due 8/26/22.
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:Hope DeBenedetti
LICENSING EVALUATOR NAME:Dina Alviso
LICENSING EVALUATOR SIGNATURE:
DATE: 08/17/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/17/2022


LIC809 (FAS) - (06/04)
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