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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496800208
Report Date: 07/31/2023
Date Signed: 07/31/2023 02:29:36 PM


Document Has Been Signed on 07/31/2023 02:29 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:OAK TREE RANCHFACILITY NUMBER:
496800208
ADMINISTRATOR:JOHNSON, PAMELAFACILITY TYPE:
740
ADDRESS:1482 OLIVET ROADTELEPHONE:
(707) 571-1122
CITY:SANTA ROSASTATE: CAZIP CODE:
95401
CAPACITY:6CENSUS: 5DATE:
07/31/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:28 PM
MET WITH:Claudia Patricia Magana (Staff)TIME COMPLETED:
02:44 PM
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Licensing Program Analyst (LPA) Cuadra arrived unannounced to conduct an Annual Required inspection and was greeted by staff Claudia Patricia Magana. Administrator, Pamela Johnson was not able to come, but was available by phone and gave authorization to staff to sign the report.

LPA/staff initiated a tour of the facility around 1:00 pm and made the following observations: Facility was a comfortable temperature and passageways were free from obstructions. Residents rooms were furnished per regulation. Extra hygiene products and linens were available. Facility has at least two days of perishable and one week of non-perishable foods which appeared to be of quality and stored per regulation. Hot water temperature in bathrooms used by residents measured at 113.9 and 115.2 degrees F which are within the range of 105 to 120 degrees F allowed per regulation. Two fire extinguisher was last serviced May 2023. One carbon monoxide detector in the hallway was tested and properly working. Last disaster drill conducted on May 2023. Working auditory alarms are placed on all exits. Disinfectants and cleaning solutions were stored inaccessible to residents. Required postings were observed. Administrator Certificate for Pamela Johnson 6018738740, expires on 7/27/2024. Medications were reviewed, centrally stored and locked.

LPA initiated file review at 1:30 pm. LPA reviewed five residents files, all residents files have a current medical assessment and care plans updated within the last 12 months. Staff records were locked in the facility office, staff on duty was able to provide proof of their CPR/1st aid. LPA will return to review staff files to ensure that staff have their files current and technical violation was issued.

Licensee agreed to submit updates of the following documents by 8/11/23: Administrative Organization (LIC309), Designation of Administrative Responsibility (LIC308), Personnel Report (LIC500), Liability Insurance, LIC 610 Emergency Disaster Plan (If changes) and Infection Control Plan (If changes).
Exit interview was conducted with staff a copy of this report was provided.
SUPERVISOR'S NAME: Bethany MoellersTELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Marisol CuadraTELEPHONE: (707) 588-5078
LICENSING EVALUATOR SIGNATURE:
DATE: 07/31/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/31/2023
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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