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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496803811
Report Date: 05/22/2026
Date Signed: 05/22/2026 12:36:46 PM

Document Has Been Signed on 05/22/2026 12:36 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:LIVE OAK REST HOMEFACILITY NUMBER:
496803811
ADMINISTRATOR/
DIRECTOR:		RAY, NICHOLASFACILITY TYPE:
740
ADDRESS:604 LIVE OAK AVENUETELEPHONE:
(707) 347-7294
CITY:SEBASTOPOLSTATE: CAZIP CODE:
95472
CAPACITY: 6CENSUS: 5DATE:
05/22/2026
TYPE OF VISIT:Case Management - Legal/Non-complianceUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:00 AM
MET WITH:Nicholas Ray (Licensee)TIME VISIT/
INSPECTION COMPLETED:
12:55 PM
NARRATIVE
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Licensing Program Analyst (LPA) Cuadra conducted an unannounced case management Legal/ Non-compliance inspection to this facility and deficiencies found during complaint # 21-AS-20260505100622 investigation, LPA met with Licensee Nicholas Ray. LPA was following up on items that were concerning and ensure compliance with Non-Compliance Conference dated 03/04/2026:

87405 (a) Administrator - Qualifications and Duties – Licensee failed to provide required information and documentation to carry out the solvency audit for the facility. On 4/27/26, the department’s financial unit sent an engagement letter regarding solvency audit process initiated after lack of commitment from the Licensee to provide requested financial documents pertinent to the facility. During today’s visit, LPA learned that Licensee has not submitted the requested forms and supporting documentation, but its planning to submit it timely.

87213 Finances - The licensee failed to have a financial plan that conforms to the requirements of Section 87155...shall maintain adequate financial records; submit such financial reports as may be required upon the written request of the licensing agency. The department has requested forms (LIC 401, 401A, 403 & 403A) & supporting documentation needed to conduct solvency audit to ensure facility is not in financial distress.

During complaint # 21-AS-20260505100622 investigation, LPA learned after requesting resident’s (R1) hospice intake documentation to determine staging of R1's pressure injuries on 5/15/2026 when Licensee told LPA that R1 passed away on 5/5/26. Licensee could not provide an answer why they did not report to the department that R1 passed away on 5/5/26. Upon arrival, LPA smelled strong urine odor at the facility. Per Licensee, its in the process to clean the carpet to resolve the odor present at the facility. Deficiencies are cited from the California Code of Regulations (CCR), and/or the Health and Safety Code. Failure to correct the cited deficiency, on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

NAME OF LICENSING PROGRAM MANAGER: Bethany Moellers
NAME OF LICENSING PROGRAM ANALYST: Marisol Cuadra
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 05/22/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/22/2026
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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California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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Document Has Been Signed on 05/22/2026 12:36 PM - It Cannot Be Edited


Created By: Marisol Cuadra On 05/22/2026 at 11:31 AM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: LIVE OAK REST HOME
FACILITY NUMBER: 496803811

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/22/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
06/05/2026
Section Cited
CCR
87211(a)(1)(D)

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87211 Reporting Requirements (1) A written report shall be submitted to the licensing agency and to the person responsible for the resident within 7 days of the occurrence of any of the events specified in (A) through (D) below…This requirement has not been met as evidence by:
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Licensee to ensure incidents are reported per regulation. Licensee agrees to review regulation 87211 and conduct training for all staff on reporting requirements. Evidence of completed training to be submitted to CCL by POC date of 06/05/2026..
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Based on LPA’s/Licensee records review and interviews, the licensee failed to notify the department within 7 days of occurrence that R1 passed away on 5/5/26, which poses a potential risk to the health & safety of residents in care.


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Type B
06/05/2026
Section Cited
CCR87303(a)(1)

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87303 Maintenance and Operation (a) The facility shall be clean, safe, sanitary & in good repair at all times... (1) Floor surfaces in bath, laundry & kitchen areas shall be maintained in a clean, sanitary, and odorless condition. This requirement has not been met as evidence by:
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Licensee to ensure that the facility is sanitary, clean & odorless at all times; Licensee to determine the way to control the odor & submit an LIC 9098 self certification that the facility is free of odor by POC due date 06/05/2026.
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Based on LPAs/Licensee and interviews with Licensee, the licensee failed to ensure that the facility was sanitary & odor free. LPA observed a strong urine smell in the facility, which poses a potential risk to the health & safety of the residents.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Bethany Moellers
NAME OF LICENSING PROGRAM MANAGER:
Marisol Cuadra
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 05/22/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/22/2026


LIC809 (FAS) - (06/04)
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