<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486804121
Report Date: 01/16/2025
Date Signed: 01/16/2025 04:54:22 PM

Document Has Been Signed on 01/16/2025 04:54 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/
DIRECTOR:		LOMO,PHOEBEFACILITY TYPE:
740
ADDRESS:800 TREE DUCK WAYTELEPHONE:
(707) 688-7512
CITY:SUISUN CITYSTATE: CAZIP CODE:
94585
CAPACITY: 6CENSUS: 6DATE:
01/16/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:20 PM
MET WITH:Mary Grace Defeo, Resident Care DirectorTIME VISIT/
INSPECTION COMPLETED:
04:53 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
On 01/16/2025, Licensing Program Analyst (LPA) Jilll Nakagawa arrived at the facility unannounced to conduct a 1-Year Required Annual Inspection. LPA met with Mary Grace Defeo, resident care director and explained the purpose of the visit. Licensee was contacted by phone and arrived shortly.

LPA Nakagawa and Ms. Defeo toured facility together to ensure health and safety of residents in care. Areas toured include but are not limited to: common areas, resident bedrooms, and common restrooms. LPA observed the facility to be clean, in good repair and odor-free. Each bathroom to have the necessary grab bars, non-skid flooring or shower chair, paper towels, trash can with lids. LPA observed each bedroom to have the necessary furnishings with working lights and windows with screens.

Facility has a 2-day perishable and a 7-day non-perishable amount of food and sharps to be locked. Hot water temperature was measured within the required range. LPA observed several fire extinguishers, fire detectors, and carbon monoxide detectors throughout out the facility. LPA observed the first aid kit to be complete and ready for use.

LPA reviewed a total of 5 residents' files; 3 of 5 were missing the Inventory list and 1 resident's information informing of possible prohibited condition; and five (5) staff files which were reviewed. 5 of 5 were missing training documentation.

LPA requested resident R1 to be sent out for immediate assessment.

(Continued on 809-C)

SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Jill Nakagawa
LICENSING EVALUATOR SIGNATURE: DATE: 01/16/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/16/2025
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 8
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: 01/16/2025
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
(Continued from 809)

LPA will continue the annual inspection at a later time; to further review training of staff and to clarify the status and condition of R1.


Deficiencies cited from the California Code of Regulations, Title 22, Division 6 of California Regulation. Appeal rights given. Failure to correct the deficiencies and/or repeat deficiencies within a 12-month period may result in civil penalties.


LPA requested the following documents be sent to CCL by COB 01/22/2025:

LIC 308 Designated Facility Responsibility
LIC 500 Personnel Summary
LIC 610 Emergency Disaster Plan
LIC 9020 Register of Facility client’s/client’s
Copy of Administrator Certificate(s)
Copy of Liability Insurance
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Jill Nakagawa
LICENSING EVALUATOR SIGNATURE:

DATE: 01/16/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/16/2025
LIC809 (FAS) - (06/04)
Page: 8 of 8