496803234-12-8-2023-21-AS-MCUA-CYBUYS-20231208150025

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 496803234
Report Date: 12/08/2023
Date Signed: 12/08/2023 03:00:33 PM

Document Has Been Signed on 12/08/2023 03:00 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:	LIVING OAK HOME CARE		FACILITY NUMBER:	496803234
ADMINISTRATOR:	MUTUNGA, EMMA SILA		FACILITY TYPE:	740
ADDRESS:	529 LIVING OAK COURT		TELEPHONE:	(707) 585-1246
CITY:	SANTA ROSA	STATE: CA	ZIP CODE:	95401
CAPACITY:	5	CENSUS: 4	DATE:	12/08/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	12:24 PM
MET WITH:	Emma Mutunga (Licensee)		TIME COMPLETED:	03:15 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 conducted an unannounced Annual Required – 1 yr. and met with Licensee Emma Mutunga. There were 3 residents present at the facility. LPA/staff toured the facility around 12:30pm. The facility was found to be clean and at a comfortable temperature with all exits free from obstruction. Resident’s bedrooms, common areas, kitchen & food storage areas were inspected. Fire Extinguishers were found to be last charged on December 2023. smoke detectors & carbon monoxide detectors were found to be operational during the visit. Last disaster drill was conducted on 10/01/2023. Hot water temperature; it measured 111.4 and 113.1 degrees F which is within acceptable regulations of 105 to 120 degrees F in 2 out of 2 resident’s bathroom faucets. There was a supply of cleaners, hygiene products and paper products available for residents. All resident’s bedrooms have lighting & appropriate furnishings. Toxins are stored in a cabinet in the garage that was locked at time of inspection. Medication is centrally stored and locked in a closet located in the kitchen. Fire extinguishers were last inspected December, 2019. Smoke/Carbon Monoxide detectors throughout the facility were tested and operational. Smoke alarms are hardwired. Auditory alarms were functional at time of inspection. Required postings observed. During today's visit, LPA discussed with Licensee about no activities been observed while LPA was visiting the facility. Per Licensee, residents do prefer not to participate in activities, they prefer to watch television or read the newspaper. At approximate 12:40pm LPA/staff observed four bananas and bag of tomatoes, which does not appear to be sufficient supply of perishable food as required by Title 22 Regulations. There was sufficient nonperishable food observed on premises. Continued on LIC809C...

SUPERVISOR'S NAME: Bethany Moellers	TELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Marisol Cuadra	TELEPHONE: (707) 588-5078
LICENSING EVALUATOR SIGNATURE:	DATE: 12/08/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/08/2023

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: LIVING OAK HOME CARE	FACILITY NUMBER: 496803234
	VISIT DATE: 12/08/2023

NARRATIVE

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Continues from LIC809...

At approximate 1:00pm LPA initiated a review of 3 staff and 4 resident files. All resident's files are current with their medical assessments and care plans. 3 out of 3 staff files have active CPR/first aid certificates and required training hours. Administrator Certificate for Emma Mutunga, 6003067740, expires 4/18/2025.

At approximate 2:00pm LPA/Licensee conducted spot check of medications and found resident's (R1) medications were not current into the Centrally Stored Medication. Licensee agreed to review and update the Centrally Stored Medication Records.

LPA requested updates of the following forms by 12/15/2023: LIC500 - Personnel Report, LIC308 Designated Administrative Responsibility, copy of control of property, LIC610E - Emergency Disaster Plan and Certificate of 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. Exit interview was conducted with Licensee and a copy of this report was provided.

SUPERVISOR'S NAME: Bethany Moellers	TELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Marisol Cuadra	TELEPHONE: (707) 588-5078
LICENSING EVALUATOR SIGNATURE:	DATE: 12/08/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/08/2023

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 12/08/2023 03:00 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: LIVING OAK HOME CARE	FACILITY NUMBER: 496803234
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 12/08/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87555(b)(26)

General Food Service Requirements

(b) The following food service requirements shall apply: (26) Supplies of nonperishable foods for a minimum of one week and perishable foods for a minimum of two days shall be maintained on the premises. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on LPA/Licensee observation and interview, the licensee did not comply with the section cited above by not ensuring that there was at least a 2 day supply of perishable foods for 31 residents which poses an immediate health & safety risk for residents in care.
	POC Due Date: 12/09/2023
	Plan of Correction
1 2 3 4	Licensee will submit a plan of how they will monitor food and adjust to ensure sufficient supply of perishable is available for residents in care. Plan for future compliance along with food receipt to be submitted to CCL by POC due date.

Type A

Section Cited

CCR

87465(a)(6)

Incidental Medical and Dental Care Services

(6) When requested by the prescribing physician or the Department, a record of dosages of medications which are centrally stored shall be maintained by the facility. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above by not maintaining a Centrally Stored Medication Log which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 12/09/2023
	Plan of Correction
1 2 3 4	Facility to review and update the Centrally Stored Medication Log by POC due date. Licensee will submit self-certification LIC9098 notifying CCL that CSMR its current. LPA will return to review.

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: Marisol Cuadra	TELEPHONE: (707) 588-5078
LICENSING EVALUATOR SIGNATURE:	DATE: 12/08/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/08/2023

LIC809 (FAS) - (06/04)

Page: 3 of 4

Document Has Been Signed on 12/08/2023 03:00 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: LIVING OAK HOME CARE	FACILITY NUMBER: 496803234
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 12/08/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87219(a)

Planned Activities

(a) Residents shall be encouraged to maintain and develop their fullest potential for independent living through participation in planned activities. The activities made available shall include: This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on LPA/Licensee observation and interview, the licensee did not comply with the section cited above by providing engaging activities for residents in care, which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 12/15/2023
	Plan of Correction
1 2 3 4	Licensee agreed to revise current activity calendar and update it with engaging activities for residents in care by POC due date to clear the deficiency.

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: Bethany Moellers	TELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Marisol Cuadra	TELEPHONE: (707) 588-5078
LICENSING EVALUATOR SIGNATURE:	DATE: 12/08/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/08/2023

LIC809 (FAS) - (06/04)

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