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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496803811
Report Date: 06/10/2025
Date Signed: 06/10/2025 12:15:30 PM

Document Has Been Signed on 06/10/2025 12:15 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:LIVE OAK REST HOMEFACILITY NUMBER:
496803811
ADMINISTRATOR/
DIRECTOR:		RAY, NICHOLASFACILITY TYPE:
740
ADDRESS:604 LIVE OAK AVENUETELEPHONE:
(707) 347-7294
CITY:SEBASTOPOLSTATE: CAZIP CODE:
95472
CAPACITY: 6CENSUS: 5DATE:
06/10/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:50 AM
MET WITH:Nick Ray (Licensee)TIME VISIT/
INSPECTION COMPLETED:
12:30 PM
NARRATIVE
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Licensing Program Analyst (LPA) Cuadra conducted an unannounced Annual Required Inspection and met with Licensee Nicholas Ray. Licensee informed of outstanding fees of $247.50.

LPA/Licensee initiated a tour of the facility at 9:00 am. Facility passageways were free of obstruction and comfortable temperature. Smoke detectors and carbon monoxide was tested and operational. Two fire extinguishers were charged and serviced November 2024. Working auditory alarms are placed on all exits. Disinfectants and cleaning solutions were stored inaccessible to residents. Hygiene and bedding supplies were available. The facility has supplies of non-perishable foods for a minimum of one week and perishable foods for a minimum of two days maintained on the premises. Last disaster drill have been conducted within the last quarter (6/1/25). Required postings were observed. During tour of the facility LPA/Licensee observed a intake vent that needs cover located in the hallway leading to bedroom #4 (technical violation issued).

At approximate 9:15 am LPA/Licensee observed hot water temperature measured at 129.9 and 134.8 degrees F which is not within the range allowed per regulation. Licensee adjusted water heater immediately. At approximately 9:30am LPA/Licensee had a conversation regarding no activities were conducted during LPA's visit. According to Licensee, there are some residents that go out for a quick walk, but there are others that no have any interest on doing them (technical violation issued).
Continues on LIC809C...
NAME OF LICENSING PROGRAM MANAGER: Bethany Moellers
NAME OF LICENSING PROGRAM ANALYST: Marisol Cuadra
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 06/10/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/10/2025
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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California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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Document Has Been Signed on 06/10/2025 12:15 PM - It Cannot Be Edited


Created By: Marisol Cuadra On 06/10/2025 at 11:43 AM
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: LIVE OAK REST HOME
FACILITY NUMBER: 496803811

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/10/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
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/Licensee's observation, the licensee did not comply with the section cited above in two out of two faucets used by residents in care water measured 129.9 and 134.8 which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 06/11/2025
Plan of Correction
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Licensee adjusted water heater immediately. Licensee will submit pictures as proof that water is within compliance to CCL by POC due date.
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.
Bethany Moellers
NAME OF LICENSING PROGRAM MANAGER:
Marisol Cuadra
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 06/10/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/10/2025


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 06/10/2025 12:15 PM - It Cannot Be Edited


Created By: Marisol Cuadra On 06/10/2025 at 11:43 AM
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: LIVE OAK REST HOME
FACILITY NUMBER: 496803811

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/10/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87458(a)
Medical Assessment
(a) Prior to a person's acceptance as a resident, the licensee shall obtain documentation of a medical assessment, signed by a licensed medical professional acting within the scope of their practice and made within the last year, to be kept in the resident's record.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA's/Licensee observation, interview and record review, the licensee did not comply with the section cited above in one out of five resident's medical assessment were not updated which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/27/2025
Plan of Correction
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Licensee agreed to obtain a current medical assessment for R1. Licensee will submit LIC9098 self-certification form to CCL ensuring their compliance with regulation by POC due date of 6/27/25.
Type B
Section Cited
CCR
87463(a)
Reappraisals
(a) The pre-admission appraisal, as specified in Section 87457, Pre-Admission Appraisal, shall be updated, in writing as frequently as necessary or once every 12 months, whichever occurs first, to note significant changes in condition, as defined in Section 87101, Definitions, and to keep the appraisal accurate. For the purposes of this section, the updated pre-admission appraisal shall be referred to as the reappraisal.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA's/Licensee observation, interview and record review, the licensee did not comply with the section cited above in two out of five residents (R1& R2) care plans needs to be updated which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/27/2025
Plan of Correction
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Licensee agreed to conduct an assessment with resident (R1 & R2). Licensee will submit LIC9098 self-certification form to CCL ensuring that they are in compliance with regulation by POC due date of 6/27/25.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Bethany Moellers
NAME OF LICENSING PROGRAM MANAGER:
Marisol Cuadra
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 06/10/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/10/2025


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 06/10/2025 12:15 PM - It Cannot Be Edited


Created By: Marisol Cuadra On 06/10/2025 at 11:43 AM
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: LIVE OAK REST HOME
FACILITY NUMBER: 496803811

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/10/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87507(a)(1)
Admission Agreements
(a) The licensee shall complete an individual written admission agreement, as defined in Section 87101(a), with each resident or the resident's representative, if any. (1) The text of the admission agreement, including any attachments and modifications, shall be:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA's/Licensee observation, interview and record review, the licensee did not comply with the section cited above in five out of five resident's admission agreements indicating the use of video surveillance in common areas which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/27/2025
Plan of Correction
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Licensee agreed to elaborate an addendum to current admissions agreements of all five residents and have their responsible parties to sign it if they agree with it. Licensee will submit LIC9098 self-certification form to CCL ensuring their compliance with this regulation by POC due date of 6/27/25.
Type B
Section Cited
CCR
87156(b)(1)(F)

87156(b)(1)(F) Licensing Fees. In addition to fee set forth in subdivision , the department shall charge the following.. licensee fails to pay the annual licensing fee on or before the due date as indicated by postmark on the payment. This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA's/Licensee observation, interview and record review, the licensee did not comply with the section cited above as of 6/10/25 licensing/late fees equals to $247.50, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/27/2025
Plan of Correction
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The Licensee shall pay the outstanding fees and submit proof that they have paid them to CCL by POC due date of 6/27/25.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Bethany Moellers
NAME OF LICENSING PROGRAM MANAGER:
Marisol Cuadra
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 06/10/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/10/2025


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: LIVE OAK REST HOME
FACILITY NUMBER: 496803811
VISIT DATE: 06/10/2025
NARRATIVE
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Continued from LIC809...

During tour of the facility LPA/Licensee observed a camera located in the facility common area. Previously, LPA/Licensee discussed that if there were cameras located in common areas, all resident's admission agreements were needed to be updated reflecting the use of cameras without audio in common areas. However, during file review it was revealed that admission agreements were not updated as instructed by LPA during last annual conducted on 7/30/24 to indicate the use of surveillance cameras in the common areas. Licensee agreed to elaborate an addendum to admission agreements.

LPA initiated file review at 10:00 am. LPA reviewed five residents files and three staff files. One out of five residents (R1) needs medical assessment to be updated. Two out of five resident's (R1 & R2) needs service plans needs to be updated. LPA/Licensee discussed Dementia regulation changes and provided resources including LIC602A form for their review. All four out of four staff do have current First Aid/CPR certificates and 20 hours of additional required training. Administrator Certificate for Nicholas Ray, 6027071740, expires on 6/24/2025. Medications and medication records were reviewed.

Licensee to submit updates of the following documents by 6/27/2025: Designation of Administrative Responsibility (LIC308), Personnel Report (LIC500) and copy of liability Certificate.

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 Licensee and copy of this report was given.

NAME OF LICENSING PROGRAM MANAGER: Bethany Moellers
NAME OF LICENSING PROGRAM ANALYST: Marisol Cuadra
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 06/10/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/10/2025
LIC809 (FAS) - (06/04)
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