496801362-8-15-2023-21-AS-DALO-CUR269-20230815170647

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 496801362
Report Date: 08/15/2023
Date Signed: 08/15/2023 05:06:56 PM

Document Has Been Signed on 08/15/2023 05:06 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 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: 6	DATE:	08/15/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	11:05 AM
MET WITH:	Sandra(Sam) Ambrecht-Lead Caregiver		TIME COMPLETED:	05:10 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 8/15/23 at approximately 11:05am, and met with Sandra Ambrecht, lead caregiver. Licensee/Administrator Pamela Johnson was notified of LPA's arrival. Facility has an approved dementia plan of operation. There is an approved hospice waiver for one(1) resident. 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 six(6) residents in care; One(1) resident is on hospice services. The LPA reviewed six(6) 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 107.9F. All exits were clear and unobstructed. The bathrooms all have grab bars as needed. Showers have mats/non-slip flooring for resident use. Facility has sufficient furnishings for resident use. Facility has sufficient lighting throughout the facility, in resident rooms, bathrooms, and common areas. LPA observed a sufficient supply of food, perishable and nonperishable. Facility had all toxins/disinfectants locked up and inaccessible to residents in care. All medications were locked up and inaccessible to residents in care. Continued on LIC809C....

SUPERVISOR'S NAME: Hope DeBenedetti	TELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Dina Alviso	TELEPHONE: (707) 588-5082
LICENSING EVALUATOR SIGNATURE:	DATE: 08/15/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/15/2023

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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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 LODGE	FACILITY NUMBER: 496801362
	VISIT DATE: 08/15/2023

NARRATIVE

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All postings were up and visible to all as required. Facility had a sufficient supply of hygiene products, paper products, and personal protective equipment(PPE) for use as needed. Fire extinguishers, two(2), were serviced and tagged as required -expires 7/3/24. Per facility fire drill reviews, last drills conducted were Fire & Earthquake, held on 4/1/23 and 6/1/23. All smoke alarms, eight(8), were working properly during the inspection. The carbon monoxide detector was part of the smoke alarm check, one of the hardwired alarms is also a carbon monoxide detector, it was working properly during the inspection.

LPA is requesting the following documents be updated and submitted by 9/15/23:
LIC308 - Designation of Administrator Responsibility
LIC610E-Emergency Disaster Plan (update as needed & submit)
LIC400 Handling of Client Cash Resources
Copy of Surety Bond if handling cash.
Copy of Current Liability Insurance
Copy of Updated Infection Control Plan
Copy of Administrator Certificate

The LPA observed resident room four(4) to have a strong smell of urine odor. The room is rugged, and the resident is incontinent. LPA discussed with the staff regulations on incontinent care, and ensuring the facility is free of urine odors.. The room is rugged, and the resident is incontinent. LPA discussed with the staff regulations on incontinent care, and ensuring the facility is free of urine odors. This deficiency will be cited, 87625(b)(3) Managed Incontinence, Ensuring that incontinent residents are kept clean and dry and that the facility remains free of odors from incontinence, see LIC809D.

The following deficiency was cited from the California Code of Regulations, Title 22, Division 6, Chapter 8 of California Regulation.
Failure to correct the deficiency(s) and/or repeat deficiencies within a 12 month period may result in civil penalties.

Exit interview conducted with Lead Caregiver
Appeal Rights provided to the Administrator.

SUPERVISOR'S NAME: Hope DeBenedetti	TELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Dina Alviso	TELEPHONE: (707) 588-5082
LICENSING EVALUATOR SIGNATURE:	DATE: 08/15/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/15/2023

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 08/15/2023 05:06 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 LODGE	FACILITY NUMBER: 496801362
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 08/15/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87625(b)(3)

Managed Incontinence

(b) In addition to Section 87611, General Requirements for Allowable Health Conditions, the licensee shall be responsible for the following: (3) 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 on LPA's observation, resident room four(4) has a very strong urine odor. The room is rugged, and the resident is incontinent. LPA discussed with the staff regulations on incontinent care, and ensuring the facility is free of urine odors. the licensee did not comply with the section cited above in [one] out of [six] resident rooms, which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 08/29/2023
	Plan of Correction
1 2 3 4	Licensee/Administrator to ensure the facility is kept free of urine odors. Ensure resident room 4 is cleaned and free of urine odors. Submit plan of correction and self certification that this has been completed. Include a maintenance plan to maintain the facility and resident room 4 free of urine odors. POC due 8/29/23.

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.

SUPERVISOR'S NAME: Carla Martinez	TELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Dina Alviso	TELEPHONE: (707) 588-5082
LICENSING EVALUATOR SIGNATURE:	DATE: 08/15/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/15/2023

LIC809 (FAS) - (06/04)

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