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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486804121
Report Date: 06/27/2023
Date Signed: 06/27/2023 10:51:25 AM


Document Has Been Signed on 06/27/2023 10:51 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: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: 1DATE:
06/27/2023
TYPE OF VISIT:Post LicensingUNANNOUNCEDTIME BEGAN:
09:35 AM
MET WITH:Luzviminda Gawat, CaregiverTIME COMPLETED:
10:55 AM
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Licensing Program Analyst (LPA) Jill Nakagawa made an unannounced post-licensing inspection of this licensed senior care facility at approximately 9:35 AM. LPA met with Luzviminda Gawat, caregiver. There was currently 1 resident who is receiving hospice services.

LPA toured the building and grounds which were found to be clean and in good repair. LPA observed all walkways and exits to be unobstructed. All notices that are required to be posted have been posted and are in a highly visible area. LPA observed a large activity space. The amount of fresh and nonperishable foods is within regulation. Facility kitchen, refrigerator and freezers were clean, and food was stored properly. Toxins are stored in locked cabinet in laundry room. Also under-sink storage cabinets were locked and inaccessible to residents. Water temperature measured within regulation between 112 and 114 degrees F at faucets accessible to residents. Fire extinguishers inspected were charged. 6 smoke detectors were found to be in working order, 2 Carbon Monoxide detectors were present and operational. There was enough lighting in all common areas, resident rooms, and hallways. Medication is centrally stored and secure.

LPA reviewed 1 resident record file and found it to be current with signed admission agreement and physician's orders on file. Medications are stored in a locked cabinet with Centrally Stored List of Medications records. MAR and daily records are kept on file on facility laptop. LPA reviewed staff records and found one future staff member still requiring first aid /CPR and one staff needing to renew first aid/CPR by 7/2/23. (Continued on LIC809-C)
SUPERVISOR'S NAME: Kimberley MotaTELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Jill NakagawaTELEPHONE: 707-588-5063
LICENSING EVALUATOR SIGNATURE:
DATE: 06/27/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/27/2023
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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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: TREE DUCK RESIDENTIAL CARE
FACILITY NUMBER: 486804121
VISIT DATE: 06/27/2023
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LPA found resident to be clean and comfortable. Rooms for residents were clean and well-organized and furnished as per Title 22 guidelines.

The back porch of the house is shaded and provides a safe and secure area for residents to spend time outside.

No deficiencies were found at the time of inspection. No citations issued.
SUPERVISOR'S NAME: Kimberley MotaTELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Jill NakagawaTELEPHONE: 707-588-5063
LICENSING EVALUATOR SIGNATURE:

DATE: 06/27/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/27/2023
LIC809 (FAS) - (06/04)
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