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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486804121
Report Date: 01/30/2025
Date Signed: 01/30/2025 11:59:04 AM


COMPREHENSIVE INSPECTION

Document Has Been Signed on 01/30/2025 11:59 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/
DIRECTOR:		LOMO,PHOEBEFACILITY TYPE:
740
ADDRESS:800 TREE DUCK WAYTELEPHONE:
(707) 688-7512
CITY:SUISUN CITYSTATE: CAZIP CODE:
94585
CAPACITY: 6CENSUS: 5DATE:
01/30/2025
TYPE OF VISIT:Case Management - Annual ContinuationUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:40 AM
MET WITH:Mary Grace DeFeo, Resident Care DirectorTIME VISIT/
INSPECTION COMPLETED:
11:57 AM
NARRATIVE
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LIcensing Program Analyst (LPA) Jill Nakagawa arrived unannounced to complete the Annual Continuation Inspection. LPA was granted access by care staff who contacted Mary Grace DeFeo, Resident Care Director, who arrived shortly. Administrator and Licensee were both called but unavailable at the time of visit.

LPA found 5 residents and 2 care staff at the facility. The facility was clean and sanitary and residents appeared to be well-cared for, clean and resting in beds with clean linens and rooms furnished appropriately.

There were 2 residents on hospice, which is within the guidelines of the license issued. Deficiencies are being issued for visit on 1/16/2025 finding resident (R1) found with a prohibited condition; and no hospice or proper care plan documentation found in resident records. (See attached 809-D).

Technical Advisories issued on 1/16/2025 were being corrected and near completion.

Deficiencies cited from the Health and Safety Code and 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.
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Jill Nakagawa
LICENSING EVALUATOR SIGNATURE: DATE: 01/30/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/30/2025
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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Document Has Been Signed on 01/30/2025 11:59 AM - It Cannot Be Edited


Created By: Jill Nakagawa On 01/30/2025 at 11:20 AM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: TREE DUCK RESIDENTIAL CARE
FACILITY NUMBER: 486804121

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/30/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
01/30/2025
Section Cited
HSC
1569.725(a)(1)

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Residents with Special Health Needs - 1569.725(a)(1) - Licensee to inform CCL of their intent to provide supporting care and supervision that is appropriate to the level of care that the facility is licensed to provide. Licensee may request an exception from CCL, providing formal request, care plan and other information for CCL to make a determination if exception may be granted.

This requirement is not met as evidenced by:
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Licensee immediately removed R1 for an assessment of condition. Licensee will ensure that going forward proper assessments will be completed prior to admissions. Licensee to provide proof of training to LPA showing understanding of the regulation by close of business 1/31/2025.
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Based on resident records,R1 was admitted with a restricted condition not allowed without hospice services.
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Type B
01/30/2025
Section Cited
CCR87609(b)(4)(A)

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Residents with Special Health Needs: 87609(b)(4)(A) - Licensee to ensure that all documentation between home health agency and faciity are included in resident records. This was not evidenced by:
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Licensee/Administrator to ensure that R2's and R3's resident records include documentation from hospice agencies and completed care plans including hospice care. Copies of completed care plans to be sent to LPA by 2/4/2025 COB.
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Based on LPA's inspection of residents R2 and R3 records there were no care plans or documentation from hospice agencies providing care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Kimberley Mota
LICENSING EVALUATOR NAME:Jill Nakagawa
LICENSING EVALUATOR SIGNATURE:
DATE: 01/30/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/30/2025


LIC809 (FAS) - (06/04)
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