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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496800208
Report Date: 08/18/2026
Date Signed: 08/18/2026 12:41:32 PM

Document Has Been Signed on 08/18/2026 12:41 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/
DIRECTOR:		JOHNSON, PAMELAFACILITY TYPE:
740
ADDRESS:1482 OLIVET ROADTELEPHONE:
(707) 571-1122
CITY:SANTA ROSASTATE: CAZIP CODE:
95401
CAPACITY: 6CENSUS: 5DATE:
08/18/2026
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:55 AM
MET WITH:Krystal Boyles-Ambrecht (staff)TIME VISIT/
INSPECTION COMPLETED:
12:57 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
Licensing Program Analyst (LPA) Cuadra arrived unannounced to conduct an Annual Required inspection and met with staff Krystal Boyles-Ambrecht. There are residents with a diagnosis of dementia. Required postings were observed. Annual fees are current.

LPA/staff initiated a tour of the facility and observed the following: Facility was a comfortable temperature and passageways were free from obstructions, but it was observed by staff/LPA a sink leaning against the wall located on the deck outside in the front area of the facility along with some sheet rock pieces that needed to be removed (technical violation issued). Facility has a pool that is surrounded by a locked gate to ensure resident safety. Resident rooms were furnished per regulation. Extra linens and hygiene products were available. Water temperature in resident's bathrooms measured at 114.4 and 114. 8 degrees F in bathrooms, which are within the range allowed by regulation. LPA/staff observed non-skid mat in residents' bathrooms were missing a technical violation issued, because LPA will address this deficiency in the complaint #21-AS-20260812154102. Toxins were inspected and are stored in the locked laundry room. At least two days of perishable and one week of nonperishable food was available. Fire extinguishers were last inspected May, 2026. Smoke alarms throughout the facility and carbon monoxide detector were tested and operational. Last disaster drill conducted on 1/23/2026 which is not within the last quarter (technical violation issued).

Continue on LIC809C...
Bethany Moellers
Marisol Cuadra
DATE: 08/18/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/18/2026
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 7
California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
Page: 2 of 7
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
VISIT DATE: 08/18/2026
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 LIC809...

LPA initiated file review at 9:30 am. Three staff and five resident files were reviewed. All staff first aid/CPR certificates are current and completed additional required 20 training hours. All residents have care plans updated and all medical assessments were current. During file review, LPA noticed that resident (R1) has a diagnosis of diabetes type 2, which it is been treated with insulin. According to staff, R1 has a glucose monitor attached to their body to monitor their glucose levels, but the facility staff prepares the injections for R1 to administer the injections themselves. However, R1's physician report revealed that R1 is not able to administer own injections. LPA had a conversation with staff indicating that the facility does not have a skilled professional to assist R1 with glucose injections. R1's care plan indicates the need of assistance with medications including insulin administration. Administrator agrees to contact R1's physician to obtain an updated physician report/letter indicating that R1 is able to administer injections by themselves with assistance from staff to prepare medication or they agree to hire a skilled professional. Administrator Certificate for Pamela Johnson 7005563740 expires on 7/27/28. Medication and medication records were reviewed.

Administrator will submit updates for the following documents by 8/25/26: LIC500- Personnel Report, LIC308- Designation of Administrative Responsibility and copy of Liability Insurance Certificate.

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.

Exit interview conducted with staff and a copy of this report was given.

NAME OF LICENSING PROGRAM MANAGER: Bethany Moellers
NAME OF LICENSING PROGRAM ANALYST: Marisol Cuadra
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 08/18/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/18/2026
LIC809 (FAS) - (06/04)
Page: 3 of 7
Document Has Been Signed on 08/18/2026 12:41 PM - It Cannot Be Edited


Created By: Marisol Cuadra On 08/18/2026 at 12:23 PM
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: OAK TREE RANCH
FACILITY NUMBER: 496800208

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/18/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87628(a)
Diabetes
(a) The licensee shall be permitted to accept or retain a resident who has diabetes if the resident is able to perform his/her own glucose testing with blood or urine specimens, and is able to administer his/her own medication including medication administered orally or through injection, or has it administered by an appropriately skilled professional.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on LPA's records review and interviews with staff, the licensee failed to ensure that resident (R1) was retained at the facility while not able to administer injections as per physician's report, but the facility did not ensure to hire an appropriate skilled professional or followed up with R1's physician to obtain updated physician order, which poses an immediate risk to the health and safety of residents in care.
POC Due Date: 09/01/2026
Plan of Correction
1
2
3
4
The Administrator agrees to ensure administration of injections are either performed by skilled professional or they will obtain updated doctor's order indicating that R1 is able to administer own injections and submit proof to CCL by POC due date.
Section Cited
Deficient Practice Statement
1
2
3
4
POC Due Date:
Plan of Correction
1
2
3
4
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Bethany Moellers
NAME OF LICENSING PROGRAM MANAGER:
Marisol Cuadra
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 08/18/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/18/2026


LIC809 (FAS) - (06/04)
Page: 4 of 7