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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496803811
Report Date: 06/11/2021
Date Signed: 06/11/2021 01:41:51 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928
FACILITY NAME:LIVE OAK REST HOMEFACILITY NUMBER:
496803811
ADMINISTRATOR:RAY, NICHOLASFACILITY TYPE:
740
ADDRESS:604 LIVE OAK AVENUETELEPHONE:
(707) 823-7277
CITY:SEBASTOPOLSTATE: CAZIP CODE:
95472
CAPACITY:6CENSUS: 4DATE:
06/11/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:07 PM
MET WITH:Nick Ray (Licensee)TIME COMPLETED:
02:00 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 Analysts (LPAs) Cuadra and Lopez arrived unannounced to conduct an Annual Required inspection and met with Licensee, Nick Ray. The inspection is focused on the Infection Control procedures and practices of this facility. LPAs conducted a Risk Assessment call with Licensee prior to visit.

LPAs arrived at the facility and had their temperature checked and logged into a sheet of paper. During facility tour with Licensee; 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.

Facility has submitted a mitigation program plan. Poster have not been placed at entrance, LPAs suggested to place posters at entrance and Licensee placed them while LPAs were conducting the visit. LPAs/Licensee did not observe Covid-19 related posters in resident's bathrooms that included hand-washing signs Per conversation with Licensee, he will be posting signs up on bathroom's walls. Facility checks the temperature of visitors, asks them screening questions and documented into a sign-in sheet. LPA was informed that facility is conducting surveillance testing weekly to 25% of staff. LPA confirmed that facility is checking resident and staff temperatures daily and the information is being documented. All staff have masks on during this visit. Facility staff have not completed PPE training nor have been N-95 Fit tested. Facility has PPE supplies. Residents do not typically wear masks inside the facility but have them available. Residents do however, wear masks while away from the facility.

LPAs provided the following guidance to staff:


· Complete N-95 Fit Testing for all staff
· Ensures that Covid-19 related posters are placed in resident's bathrooms.
· Complete Staff Training on infection control.

No deficiencies cited during this inspection.
SUPERVISOR'S NAME: Bethany MoellersTELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Marisol CuadraTELEPHONE: (707) 588-5078
LICENSING EVALUATOR SIGNATURE:

DATE: 06/11/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/11/2021
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 2