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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496803234
Report Date: 12/02/2022
Date Signed: 12/02/2022 09:42:08 AM

Document Has Been Signed on 12/02/2022 09:42 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:LIVING OAK HOME CAREFACILITY NUMBER:
496803234
ADMINISTRATOR:MUTUNGA, EMMA SILAFACILITY TYPE:
740
ADDRESS:529 LIVING OAK COURTTELEPHONE:
(707) 585-1246
CITY:SANTA ROSASTATE: CAZIP CODE:
95401
CAPACITY: 5CENSUS: 5DATE:
12/02/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:26 AM
MET WITH:Emma Mutunga (Licensee)TIME COMPLETED:
09:57 AM
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Licensing Program Analyst (LPA) Cuadra arrived unannounced to conduct an Annual Required inspection and met with Licensee, Emma Mutunga. The inspection is based on Infection Control practices of this facility.

LPA confirmed that facility is no longer requiring vaccination verification per recent guidance. LPA/Licensee initiated a walk-through of the facility and observed the following: Facility has COVID-19 posters throughout that include hand washing signs in bathrooms. Facility was a comfortable temperature and exits were free from obstructions. Hand sanitizer is located throughout common areas of the facility. Staff had masks on during this visit. Commonly touched surfaces are disinfected at least once per day. Facility does perform daily screening of staff and residents. Facility has a designated visitation area outside and is allowing for visitation in resident rooms per CCL guidance. Staff continue to receive training on infection control and donning and doffing of Personal Protective Equipment PPE and have been N95 fit tested. LPA/Licensee discussed visitation and activities. Facility has submitted and CCL has reviewed their Covid Mitigation Plan. Facility has more than a 30 day supply of PPE including but not limited to masks, gowns, and hand sanitizer. Facility maintains a 30 day supply of medication. Fire extinguishers were last serviced December 9, 2021. Smoke Detectors and Carbon Monoxide detector were operational. Water temperature reading was 109.8 which is within regulation.

Licensee submitted updates of the following documents:
LIC 308 Designated Administrator.
LIC 500 Personnel Summary.
LIC 610 Emergency Disaster Plan.
Liability Insurance.

No deficiencies cited during today's inspection. Exit interview conducted with licensee Emma Mutunga and a copy of this report was provided to licensee.
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Marisol Cuadra
LICENSING EVALUATOR SIGNATURE: DATE: 12/02/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/02/2022
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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