496803811-5-22-2026-21-AS-BMOS-DUMRQJ-20260601131338

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 496803811
Report Date: 05/22/2026
Date Signed: 05/22/2026 12:39:06 PM

Substantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

This is an official report of an unannounced visit/investigation of a complaint received in our office on
05/05/2026 and conducted by Evaluator Marisol Cuadra

PUBLIC

COMPLAINT CONTROL NUMBER: 21-AS-20260505100622

FACILITY NAME:	LIVE OAK REST HOME		FACILITY NUMBER:	496803811
ADMINISTRATOR:	RAY, NICHOLAS		FACILITY TYPE:	740
ADDRESS:	604 LIVE OAK AVENUE		TELEPHONE:	(707) 347-7294
CITY:	SEBASTOPOL	STATE: CA	ZIP CODE:	95472
CAPACITY:	6	CENSUS: 5	DATE:	05/22/2026
		UNANNOUNCED	TIME BEGAN:	11:00 AM
MET WITH:	Nicholas Ray (Licensee)		TIME COMPLETED:	12:56 PM

ALLEGATION(S):

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-Resident developed multiple pressure injuries in care requiring hospitalization, due to staff neglect.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Cuadra arrived unannounced to conduct a complaint investigation and delivered findings regarding the allegation listed above and met with Nicholas Ray, Licensee.

The department received a complaint allegation of resident developed multiple pressure injuries in care requiring hospitalization, due to staff neglect. The reporting party reported that facility Licensee left a resident (R1) without repositioning for extended periods of time resulting in R1 developing several pressure sores and requiring hospitalization. R1 is non-verbal, bedridden with a diagnosis of dementia. Based on records review obtained by the department revealed that on 5/02/2026, R1 was admitted to the emergency room at Providence Santa Rosa Memorial Hospital for a wound check. A wound care consult was conducted where a deep tissue injury was diagnosed on the sacrum. Also, it was observed that a small open area on the upper thoracic spine appeared to be a stage 3 pressure injury. However, the stage 3 pressure injury was never confirmed. R1 was discharged back to the care facility same day with a final diagnosis of pressure injury of the skin of the right upper back, unspecified injury stage. Continued on LIC9099C...

Substantiated

Estimated Days of Completion:

SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Marisol Cuadra
LICENSING EVALUATOR 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.

LIC9099 (FAS) - (06/04)

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Control Number 21-AS-20260505100622

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: LIVE OAK REST HOME	FACILITY NUMBER: 496803811
	VISIT DATE: 05/22/2026

NARRATIVE

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Continued from LIC9099...

On 5/03/2026, R1 was readmitted and evaluated for the same injury the day before and diagnosed with a principal diagnosis of advanced dementia and a secondary diagnosis of pressure ulcer of the sacrum, hypertension, chronic atrial fibrillation, and hypercholesterolemia, and discharged home with hospice on 5/05/2026. On 5/5/26, LPA conducted 10-day visit to the facility to initiate complaint investigation. Based on LPA’s interviews conducted with staff (S1, S2, S3 & S4), confirmed that staff were in constant communication with Licensee regarding R1’s skin condition describing it as redness observed in the area. Interviews conducted with Licensee, it was disclosed that staff have been repositioning R1 but denied that staff communicate with them about resident's pressure injuries and despite that licensee was working nights during the week as confirmed in the facility schedule. According to licensee, the assistance with incontinence care that licensee provided to R1 was limited to open R1’s depends, but not all the way off, check that R1 was dry, then close depends. On 5/15/26 LPA requested hospice intake documentation to determine staging of pressure injuries at intake, but licensee informed LPA that R1 passed away on 5/5/26 after arriving back from the hospital. LPA reviewed incident logs for this facility and was unable to find any notification from the licensee. LPA will address reporting requirements in case management. Based on records review and interviews conducted by LPA with pertinent parties, it was revealed that R1 was not sent out timely to receive medical attention. Licensee agrees to obtain and submit death certificate to the department. The preponderance of evidence standard has been met; therefore, the above allegation is found to be SUBSTANTIATED. California Code of Regulations, (Title 22, Division 6, Chapter 8), is cited on the attached LIC 9099D. Appeal Rights Given. Failure to observe change of condition which resulted in pain per hospital notes resulted in violation causing injury to person in care $500 immediate civil penalty issued.

The licensee was informed that additional civil penalties are under review by the Department per Health and Safety Code 1569.49 (f).
Exit interview conducted with Licensee and copy of this report was given.

SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Marisol Cuadra
LICENSING EVALUATOR 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

LIC9099 (FAS) - (06/04)

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Control Number 21-AS-20260505100622

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 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 A 05/23/2026 Section Cited CCR 87466	1 2 3 4 5 6 7	87466 Observation of the Resident The licensee shall ensure that residents are regularly observed for changes in physical, mental, emotional and social functioning and that appropriate assistance is provided when such observation reveals unmet needs. This requirement has not been met as evidence by:	1 2 3 4 5 6 7	The Licensee agrees to develop a procedure indicating how the facility will ensure that facility staff will regularly observe residents for changes in physical, mental, emotional & social functioning & will seek timely medical attention by POC due date 5/23/26.
	8 9 10 11 12 13 14	Based on LPA's interviews conducted with facility staff and records reviews of R1’s medical records, the facility staff failed to send R1 out timely to receive medical attention, which poses an immediate risk to the health and safety of the residents in care.	8 9 10 11 12 13 14	*** Failure to observe change of condition which resulted in pain per hospital notes resulted in violation causing injury to person in care $500 immediate civil penalty issued.
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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.

SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Marisol Cuadra
LICENSING EVALUATOR 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

LIC9099 (FAS) - (06/04)

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