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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496803234
Report Date: 06/18/2024
Date Signed: 06/18/2024 10:30:41 AM

Document Has Been Signed on 06/18/2024 10:30 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/
DIRECTOR:
MUTUNGA, EMMA SILAFACILITY TYPE:
740
ADDRESS:529 LIVING OAK COURTTELEPHONE:
(707) 585-1246
CITY:SANTA ROSASTATE: CAZIP CODE:
95401
CAPACITY: 5CENSUS: 5DATE:
06/18/2024
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:46 AM
MET WITH:Emma Mutunga (Licensee)TIME VISIT/
INSPECTION COMPLETED:
10:45 AM
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Licensing Program Analyst (LPA) Cuadra arrived unannounced to conduct a case management and met with Emma Mutunga (Licensee).

On 6/17/24 the Department received an email from licensee notifying CCL that on the same date resident (R1) was sent to the emergency room due to vomiting and blood noted on their feces. The licensee was going to follow up with an incident report when they have any additional information.

During today's visit, LPA was told by licensee that R1 was declining on their appetite since last week, which it was notified to their responsible party including their social worker. However, it was determined to transport R1 to the hospital after the blood was noticed by licensee. Currently, R1 is still in the hospital due to possible urinary tract infection, but they also had a blood transfusion. Based on records review, R1 did not have any history of bleeding prior to this episode. Licensee agreed to submit an incident report with updated information.

No deficiencies cited during today's visit. Exit interview was conducted with licensee and copy of this report was given.
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Marisol Cuadra
LICENSING EVALUATOR SIGNATURE: DATE: 06/18/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/18/2024
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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