496801362-10-16-2024-21-AS-DALO-DA4TVK-20241016150405

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 496801362
Report Date: 10/16/2024
Date Signed: 10/16/2024 03:04:11 PM

Document Has Been Signed on 10/16/2024 03:04 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
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME:	OAK TREE LODGE		FACILITY NUMBER:	496801362
ADMINISTRATOR:	JOHNSON, PAMELA		FACILITY TYPE:	740
ADDRESS:	6360 OLD REDWOOD HWY.		TELEPHONE:	(707) 836-7777
CITY:	SANTA ROSA	STATE: CA	ZIP CODE:	95403
CAPACITY:	6	CENSUS: 5	DATE:	10/16/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:40 AM
MET WITH:	Sandra Ambrecht-Administrator		TIME COMPLETED:	03:20 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) Alviso, arrived unannounced to conduct a Required -1 Year inspection, on 10/16/24 at approximately 9:40am, and met with Sandra Ambrecht, Administrator. Facility has an approved dementia plan of operation. There is an approved hospice waiver for one(1) resident; Currently there is one (1) resident on hospice care. The facility has a required infection control plan. The facility has a required emergency disaster plan. Fire clearance is approved for six (6) non-ambulatory. There are currently five (5) residents in care. Per file review, quarterly fire/evacuation/emergency disaster drills are being conducted as required. The LPA reviewed five (5) resident files. All files were complete. The LPA reviewed three(3) staff files. All staff have required criminal record clearance. All staff have current First Aid and CPR as required. All staff have training as required. The LPA toured the facility with caregiver Sam. Hot water was checked at 106.7 degrees Fahrenheit. All exits were clear and unobstructed. All exit doors had auditory alarms. Fire extinguishers were serviced as required, dated 7/2/24. Medications were locked up and inaccessible to residents in care. All cleaners/disinfectants were locked up and inaccessible to residents in care. There was sufficient lighting in resident rooms, hallways, bathrooms, and all common areas. LPA observed a sufficient supply of food, perishable and non-perishable. Sufficient supply observed regarding, hygiene supplies, linens, personal protective equipment (PPE), paper products, and disinfectants/cleaners. Common areas were found to be clean and orderly. Resident rooms 1, 2, 3, 4, and 6, were observed to be clean and orderly. Sufficient furnishings observed throughout the facility for resident use. Continued on LIC809C..

SUPERVISOR'S NAME: Bethany Moellers	TELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Dina Alviso	TELEPHONE: (707) 588-5082
LICENSING EVALUATOR SIGNATURE:	DATE: 10/16/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/16/2024

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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: OAK TREE LODGE	FACILITY NUMBER: 496801362
	VISIT DATE: 10/16/2024

NARRATIVE

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LPA is requesting the following documents be updated and submitted by 11/16/24:
LIC308 - Designation of Administrator Responsibility
LIC500 - Personnel Report
LIC610E- Emergency Disaster Plan -Review and submit plan if any changes. If no changes, submit last page (write at top which plan) signed & dated of when reviewed and by who.
Infection Control Plan- Review and submit plan if any changes. If no changes, submit last page (write at top which plan) signed & dated of when reviewed and by who.
Copy of LIC400 Handling of Client Cash Resources (include copy of surety bond if handling cash)
Copy of Current Liability Insurance
Resident Roster
Copy of current Administrator Certificate when received

The following deficiencies were observed by the LPA during the inspection:

LPA observed resident's (R1) room, #5,to have a very strong smell of urine, in resident's room and bathroom; The resident is incontinent per file review, and interview with staff S1. S1 stated that they are aware the room smells of urine, and has cleaned the room and bathroom daily, but can't get rid of the urine smell. S1 doesn't know if it's the resident's bathroom, toilet, flooring and/or room, such as the resident's rug. This deficiency will be cited, 87625(b)(3) Managed Incontinence-In addition to Section 87611, General Requirements for Allowable Health Conditions, the licensee shall be responsible for the following: Ensuring that incontinent residents are kept clean and dry and that the facility remains free of odors from incontinence, see LIC809D.

LPA observed that there is a outlet with a coveplate missing in resident room #1's bathroom. There is a large dirty, grease spot above the stove range on the kitchen ceiling that needs to be cleaned really well. There is a door in the kitchen where at the top of this door looks to be sheetrock (drywall) crumbling and falling apart. LPA obtained pictures. This deficiency will be cited,

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

Exit interview conducted with Administrator.
Appeal rights given to Administrator Sandra Ambrecht.

SUPERVISOR'S NAME: Bethany Moellers	TELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Dina Alviso	TELEPHONE: (707) 588-5082
LICENSING EVALUATOR SIGNATURE:	DATE: 10/16/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/16/2024

LIC809 (FAS) - (06/04)

Page: 2 of 3

Document Has Been Signed on 10/16/2024 03:04 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
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: OAK TREE LODGE	FACILITY NUMBER: 496801362
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 10/16/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87625(b)(3)

87625(b)(3) Managed Incontinence-In addition to Section 87611, General Requirements for Allowable Health Conditions, the licensee shall be responsible for the following: Ensuring that incontinent residents are kept clean and dry and that the facility remains free of odors from incontinence. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based onLPA observed resident's (R1) room, #5,to have a very strong smell of urine, in resident's room and bathroom; The resident is incontinent per file review, and interview with staff S1. S1 stated that they are aware the room smells of urine, and has cleaned the room and bathroom daily, but can't get rid of the urine smell. S1 doesn't know if it's the resident's bathroom, toilet, flooring and/or room, such as the resident's rug, the licensee did not comply with the section cited above which poses/posed a potential health, safety and a personal rights risk to persons in care.
	POC Due Date: 10/28/2024
	Plan of Correction
1 2 3 4	Licensee/Administrator to ensure that the resident's R1's room, and bathroom, is inspected to find where and why the resident's room and bathroom smell of strong urine odors, ensuring the resident's room, bathroom, and the facility are free from incontinent odors/urine odors. Submit how the resident's room was cleaned, if anything was repaired and/or replaced, and also submit a mainteenance plan to keep this resident's room and bathroom free of incontinent odors. POC due 10/28/24.

Type B

Section Cited

CCR

87303(a)

87303(a) Maintenance and Operation The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	LPA observed there is a outlet with a coveplate missing in resident room #1's bathroom. There is a large dirty, grease spot above the stove range on the kitchen ceiling that needs to be cleaned really well. There is a door in the kitchen where at the top of this door looks to be sheetrock (drywall) crumbling and falling apart. LPA obtained pictures, the licensee did not comply with the section cited above which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 10/31/2024
	Plan of Correction
1 2 3 4	Licensee/Administrator to ensure that the kitchen ceiling is cleaned welll and any dirt and/or grease is removed. Ensure the outlet coverplate resident's bathroom is put on. Ensure that the kitchen wall around the door is repaired and/or replaced as needed and required. Submit photos, and include how each item was cleaned and/or repaired per corrections. POC due 10/31/24.

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 Moellers	TELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Dina Alviso	TELEPHONE: (707) 588-5082
LICENSING EVALUATOR SIGNATURE:	DATE: 10/16/2024

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/16/2024

LIC809 (FAS) - (06/04)

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