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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496800208
Report Date: 08/04/2023
Date Signed: 08/04/2023 12:44:36 PM


COMPREHENSIVE INSPECTION

Document Has Been Signed on 08/04/2023 12:44 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:
08/04/2023
TYPE OF VISIT:Case Management - Annual ContinuationUNANNOUNCEDTIME BEGAN:
11:48 AM
MET WITH:Claudia Patricia Magana (Staff)TIME COMPLETED:
12:59 PM
NARRATIVE
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Licensing Program Analyst (LPA) Cuadra arrived unannounced to conduct an Annual Continuation 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 returned to the facility to review staff files that were unavailable including proof of First Aid and CPR during the last visit conducted on 7/31/2023.

During today's visit, LPA reviewed two out of two staff files and their CPR/1st aid certification training were updated after the inspection conducted on 7/31/23. CPR/1st aid certifications on file were dated 7/31/23. LPA discussed with Administrator the importance of having current training certification on file at all times. Administrator agreed to maintain current staff files.

Licensee provided updates of the following documents: Administrative Organization (LIC309), Designation of Administrative Responsibility (LIC308) and Liability Insurance

Deficiencies cited from the California Code of Regulations, Title 22, Division 6 of California Regulation. Appeal rights given. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties.
SUPERVISOR'S NAME: Bethany MoellersTELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Marisol CuadraTELEPHONE: (707) 588-5078
LICENSING EVALUATOR SIGNATURE:
DATE: 08/04/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/04/2023
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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Document Has Been Signed on 08/04/2023 12:44 PM - It Cannot Be Edited

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: OAK TREE RANCH
FACILITY NUMBER: 496800208

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/04/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
08/18/2023
Section Cited
HSC
1569.618(c)(3)

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1569.618 Administration/management of RCFE: c) The facility shall employ, & the administrator shall schedule...: (3) Ensure that at least 1 staff member who has cardiopulmonary resuscitation (CPR) training & 1st first aid training is on duty/on the premises at all times....This requirement is not met as evidenced by:
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Facility agrees to maintain staff files in this facility including proof of First Aid and CPR Certificates by POC due date.
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Based on observation, the licensee did not comply with the section cited above in 2 out of 2 staff not having proof of a First Aid and CPR Certificate, which poses/posed a potential health, safety or personal rights risk to persons in 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: Bethany MoellersTELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Marisol CuadraTELEPHONE: (707) 588-5078
LICENSING EVALUATOR SIGNATURE:
DATE: 08/04/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/04/2023
LIC809 (FAS) - (06/04)
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