496803811-3-7-2022-21-AS-BMOS-CCCTCK-20220309133652

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 496803811
Report Date: 03/07/2022
Date Signed: 03/07/2022 02:48:14 PM

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
12/30/2021 and conducted by Evaluator Marisol Cuadra

PUBLIC

COMPLAINT CONTROL NUMBER: 21-AS-20211230102825

FACILITY NAME:	LIVE OAK REST HOME		FACILITY NUMBER:	496803811
ADMINISTRATOR:	RAY, NICHOLAS		FACILITY TYPE:	740
ADDRESS:	604 LIVE OAK AVENUE		TELEPHONE:	(707) 823-7277
CITY:	SEBASTOPOL	STATE: CA	ZIP CODE:	95472
CAPACITY:	6	CENSUS: 4	DATE:	03/07/2022
		UNANNOUNCED	TIME BEGAN:	01:15 PM
MET WITH:	Nick Ray (Licensee)		TIME COMPLETED:	02:00 PM

ALLEGATION(S):

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-Neglect resulting in pressure injury
-Personal Rights

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Cuadra conducted an unannounced complaint investigation regarding the above allegations and met with Licensee, Nicholas Ray for the purpose of closing the complaint.

It was alleged neglect resulting in pressure injury to resident (R1). Based on records review of hospice care notes, R1 is receiving hospice services an average of two to three days per week since December 2, 2021. On 12/23/21 it was identified a Stage 1 wound on R1’s left buttocks and staff was instructed to reposition resident every two hours. Hospice records revealed on 1/6/22 wound was healing good and documentation reviewed indicates wound healed completely by 1/14/22. Based on records review and confidential interviews conducted it was revealed that R1 was refusing some care being offered and there was no information to support that facility staff neglected resulted in R1’s pressure injury. A finding that the complaint allegation neglect resulting in pressure injury is unsubstantiated meaning that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED. Continues on LIC9099C...

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Bethany Moellers	TELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Marisol Cuadra	TELEPHONE: (707) 588-5078
LICENSING EVALUATOR SIGNATURE:	DATE: 03/07/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/07/2022

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-20211230102825

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: 03/07/2022

NARRATIVE

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Continued from LIC9099...

Regarding the allegation of personal rights. Resident (R1) has communication limitations which complainant alleges resulted in personal rights violation. Based on LPA’s investigation, R1 moved in the facility on 12/2/21 and they were having a hard time transitioning to the new facility. Staff at facility are now utilizing alternative ways to communicated to resolve communication challenges through other communication sources and adjusting to meet resident’s needs. A finding that the complaint allegation personal rights is unsubstantiated meaning that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED

No deficiencies cited during today’s visit.

SUPERVISOR'S NAME: Bethany Moellers	TELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Marisol Cuadra	TELEPHONE: (707) 588-5078
LICENSING EVALUATOR SIGNATURE:	DATE: 03/07/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/07/2022

LIC9099 (FAS) - (06/04)

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