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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486804121
Report Date: 01/30/2023
Date Signed: 01/30/2023 03:03:02 PM


Document Has Been Signed on 01/30/2023 03:03 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:TREE DUCK RESIDENTIAL CAREFACILITY NUMBER:
486804121
ADMINISTRATOR:GAWAT, HAZEL MAEFACILITY TYPE:
740
ADDRESS:800 TREE DUCK WAYTELEPHONE:
(707) 688-7512
CITY:SUISUN CITYSTATE: CAZIP CODE:
94585
CAPACITY:6CENSUS: 0DATE:
01/30/2023
TYPE OF VISIT:PrelicensingANNOUNCEDTIME BEGAN:
12:50 PM
MET WITH:Hazel Gawat, ApplicantTIME COMPLETED:
03:15 PM
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Licensing Program Analyst (LPA) Karina Canela conducted a pre-licensing inspection on 01/30/2023. LPA met with Hazel Gawat, Applicant, who will be the Administrator when the facility is approved for licensure. Applicant has approval from the Centralized Applications Bureau (CAB) for a hospice waiver to retain or accept a total of 2 residents receiving or initiating hospice services. A Dementia Care Plan of Operation has been submitted to CAB. The facility has a fire clearance approval from the City of Suisun City Fire Department for 5 non-ambulatory residents (bedrooms #1-4), 1 bedridden (bedroom #4 only) for a total capacity 6 . Facility will operate with 24 hour/ 7 days a week staff and Licensee will ensure sufficient staffing at all times.
During today’s visit LPA observed the following items:
· COVID-19 postings and screening station at entrance
· Lockable separate cabinets for medications, toxins, and knives.
· All exits were unobstructed
· 6 hardwired combination smoke and carbon monoxide detectors, plus 1 single carbon monoxide detector, were tested and observed to be operational
· First Aid kit, night-lights, and flashlights for emergency lighting
· Supply of linens, paper products, and hygiene supplies available
· Grab bars and non-slip mats in 2 of 2 bathrooms.
· Fire Extinguisher charged and purchased new on 01/04/2023 (receipt available for review)
· Required furnishings in all 4 resident bedrooms
· Supplies for activities
· Administrator Certification; Required postings (Personal Rights, Emergency Plan/numbers, CCLD complaint poster, Rights of Family Councils, and Visitor Policy).

* Applicant to submit copy of Liability Insurance to Centralized Applications Bureau Analyst
Pre-licensing is complete and this facility has no corrections needed. The Component III Orientation was completed during today's visit. LPA will submit the pre-licensing application report to Centralized Applications Bureau (CAB) Analyst in Sacramento; CAB Analyst will notify applicant of application status.
SUPERVISOR'S NAME: Hope DeBenedettiTELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Karina CanelaTELEPHONE: 707-588-5054
LICENSING EVALUATOR SIGNATURE:
DATE: 01/30/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/30/2023
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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