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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496803811
Report Date: 12/17/2021
Date Signed: 12/17/2021 11:04:51 AM

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:
12/17/2021
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
09:57 AM
MET WITH:Nick Ray (Licensee)TIME COMPLETED:
11:00 AM
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LPA Cuadra arrived unannounced to conduct a case management inspection and met with Licensee, Nick Ray. LPA conducted risk assessment with staff. LPA arrived at the facility and had her temperature checked and was logged into a sign-in sheet.

LPA is following up on a new admission of resident (R1) who appears to have some behavioral tendencies. LPA obtained a copy of R1’s care plan, admission agreement and pre-appraisal. During today's visit LPA toured the facility and observed that R1 have their own room and is non-ambulatory. Licensee is working closely with their Physician to discuss about R1’s behavioral plan to ensure that all residents are protected and it is actively looking to hire and train additional staff to meet needs of all residents in care. Licensee agreed to obtain responsible parties signature and submit updated LIC500 to CCL for LPA’s review.

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

DATE: 12/17/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/17/2021
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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