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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496804179
Report Date: 01/15/2026
Date Signed: 01/15/2026 03:37:46 PM

Document Has Been Signed on 01/15/2026 03:37 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
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME:OLIVE TREE ASSISTED LIVING LLCFACILITY NUMBER:
496804179
ADMINISTRATOR/
DIRECTOR:		QUIJADA, CLAUDIAFACILITY TYPE:
740
ADDRESS:542 CARRIAGE CTTELEPHONE:
(707) 522-6822
CITY:SANTA ROSASTATE: CAZIP CODE:
95403
CAPACITY: 6CENSUS: 4DATE:
01/15/2026
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:45 PM
MET WITH:Administrator Claudia QuijadaTIME VISIT/
INSPECTION COMPLETED:
03:45 PM
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At approximately 1:45 PM Licensing Program Analyst (LPA) Stevenson arrived unannounced to conduct a required- 1 Year visit met with Licensee/Administrator Claudia Quijada. There are currently four (4) residents in care, and two (2) residents are on hospice and no residents using PRN or other supplemental oxygen.

Facility has an approved dementia plan of operation. There is an approved hospice waiver for two (2) residents. Facility has an infection control plan as required. Facility has an emergency disaster plan as required.

Facility has a fire clearance approval for a total of six non-ambulatory residents, of which two (2) may be bedridden. All locks on exterior gates are approved. The self latching fire exit gate is never to have a lock on it. The facility's last fire drill and evacuation drill was conducted 10/21/25. The facility does have emergency food, water, and miscellaneous supplies to meet the "72 hour shelter in place" requirements.

Facility was observed to be clean and without odors. Hot water in bathrooms available to residents in care measured between 105-120F as required by regulation. All exits were free and clear of obstruction. Fire extinguisher was serviced and tagged as required on 04/2025. Smoke alarms and carbon monoxide detectors were working properly during the inspection.

The backyard has outside cement patio, with furnishings for resident use, including areas providing shade for residents as needed. The facility was at a comfortable temperature for residents in care; Residents were observed to be watching television and engaging with the staff during the inspection.

Continued on LIC809C...

NAME OF LICENSING PROGRAM MANAGER: Bethany Moellers
NAME OF LICENSING PROGRAM ANALYST: Star Stevenson
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 01/15/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/15/2026
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME: OLIVE TREE ASSISTED LIVING LLC
FACILITY NUMBER: 496804179
VISIT DATE: 01/15/2026
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Continued from LIC809

Toxins and sharps that pose a potential threat to residents in care were observed to be secure and supervised.

Medications were observed to be centrally stored and locked and Medicine Administration was observed to be accurate.

LPA reviewed four (4) resident files; Resident files were complete.



LPA reviewed five (5) staff files. LPA reviewed staff training. All five(5) staff have criminal record clearance, and are associated as required. All staff had current First Aid and CPR Certification.

LPA obtained the following documents today for the facilities file:
  • LIC500 Personnel Report
  • LIC9020 Register of Facility Residents
  • LIC610E Emergency and Disaster Plan
  • Evidence of Current Liability Insurance which will expire 02/2026 and licensee was advise to submit to licensing updated Liability Insurance after 02/2026

No Deficiencies are cited



Exit interview conducted with Administrator/Licensee Claudia Quijada.
NAME OF LICENSING PROGRAM MANAGER: Bethany Moellers
NAME OF LICENSING PROGRAM ANALYST: Star Stevenson
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 01/15/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/15/2026
LIC809 (FAS) - (06/04)
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