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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 236801874
Report Date: 09/22/2023
Date Signed: 09/22/2023 10:44:14 AM

Document Has Been Signed on 09/22/2023 10:44 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:THREE OAKS, INCFACILITY NUMBER:
236801874
ADMINISTRATOR:CABIE, BENJAMINFACILITY TYPE:
735
ADDRESS:181 NORTH COURT ROADTELEPHONE:
(707) 462-1902
CITY:UKIAHSTATE: CAZIP CODE:
95482
CAPACITY: 6CENSUS: 4DATE:
09/22/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:15 AM
MET WITH:Roreli BonillaTIME COMPLETED:
11:00 AM
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At approximately 8:15AM, Licensing Program Analyst (LPA) Chris Arnhold conducted an unannounced Annual Required inspection to this facility and met with caregiver Roreli Bonilla. At approximately 8:40AM, LPA toured the building and grounds which was found to be clean and in good repair. LPA observed all walkways and exits to be unobstructed. The amount of fresh and non-perishable foods was within regulation. Toxins are secure and not accessible to clients. Medication is centrally stored and secure. There is a sufficient supply of hygiene products and linens on hand for client use. Mattress pads were in place or available for Client use. Water temperature measured within regulation between 105 and 120 degrees F at faucets accessible to clients. Fire extinguishers inspected were charged. Smoke detectors were tested and found to be in working order. Carbon Monoxide detector was present. Disaster Drills are conducted monthly.

At approximately 9:00AM, LPA reviewed 4 of 4 Client records and 2 of 4 Staff records, which were all found to be well organized. 3 of 4 clients are over the age of 60. LPA requested exception paperwork for each client. LPA observed S1 did not have documented training for G-Tube medication assistance. LPA observed there was no evidence the procedure for the care of a G-Tube has been reviewed annually. First aid and CPR certification were current in staff files reviewed. P&I monies were documented, secure and not commingled. LPA observed the appointed Administrator is not present at the facility a sufficient number of hours to ensure the proper administration of the facility.

Continued on LIC809-C...
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Christopher Arnhold
LICENSING EVALUATOR SIGNATURE: DATE: 09/22/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/22/2023
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 9
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: THREE OAKS, INC
FACILITY NUMBER: 236801874
VISIT DATE: 09/22/2023
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LPA requested the following documents to address the technical violations:

-Written plan to ensure a certified Administrator is present a sufficient number hours to provide management of the facility.

-Exception paperwork for clients over the age of 60.

-Exception paperwork for the use of postural supports.

-Self certification that G-Tube procedures are reviewed at least annually.

-Self certification that all staff have received training on assisting with G-Tube maintenance.

Updated copies of the following documents were requested for facility file and are to be submitted to CCL within 30 days of this visit:
Evidence of control of property
LIC500- Personnel Report
LIC308- Designation of Responsibility

No citations issued during today’s visit.
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Christopher Arnhold
LICENSING EVALUATOR SIGNATURE:

DATE: 09/22/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/22/2023
LIC809 (FAS) - (06/04)
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