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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 496803811
Report Date: 08/28/2025
Date Signed: 08/28/2025 10:29:57 AM

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
08/26/2025 and conducted by Evaluator Marisol Cuadra
PUBLIC
COMPLAINT CONTROL NUMBER: 21-AS-20250826155234
FACILITY NAME:LIVE OAK REST HOMEFACILITY NUMBER:
496803811
ADMINISTRATOR:RAY, NICHOLASFACILITY TYPE:
740
ADDRESS:604 LIVE OAK AVENUETELEPHONE:
(707) 347-7294
CITY:SEBASTOPOLSTATE: CAZIP CODE:
95472
CAPACITY:6CENSUS: 3DATE:
08/28/2025
UNANNOUNCEDTIME BEGAN:
08:49 AM
MET WITH:Nicholas Ray (Licensee) TIME COMPLETED:
10:44 AM
ALLEGATION(S):
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-Staff did not issue a refund to resident's authorized representative.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Cuadra conducted a complaint investigation regarding the above allegation. Licensee was out of town unable to come to the facility but was available via phone and gave authorization to staff to sign the report. LPA reviewed resident and facility records and interviewed Licensee. Per Reporting party, Resident (R1) passed away on April 9, 2025, and they removed R1’s belongings as of April 14, 2025. According to the admission agreement, the licensee agrees to refund any fees within 15 days paid in advance covering the time after the residents’ items have been removed. Based on interviews conducted by LPA with the Licensee it was confirmed that R1's personal belongings were removed from the room, and they agreed with R1’s responsible party to round down the refund to $3000, but according to the Licensee there have been some pinches. However, Licensee stated that the facility will be issuing the refund to R1’s responsible party by not later than September 15, 2025, and it was communicated to R1’s responsible party on 8/27/25 via phone. A balance is still due to be paid to responsible party/authorized representative for the remaining days. The preponderance of evidence standard has been met; therefore, the above allegations are found to be SUBSTANTIATED. California Code of Regulations, (Title 22, Division 6, Chapter 8), is being cited on the attached LIC 9099D. Appeal Rights given.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Marisol Cuadra
LICENSING EVALUATOR SIGNATURE:

DATE: 08/28/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/28/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 2
Control Number 21-AS-20250826155234
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: 08/28/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/15/2025
Section Cited
HSC
1569.652
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1569.652 Termination of admission agreement upon death of resident; removal of resident’s property; refund of fees paid; notice of contract termination and refunds.
This requirement was not met as evidenced by***
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Licensee to refund $3000 fees paid to resident's responsible party. Proof of refund to be submitted to CCL by POC due date.
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Based on LPA's record review and interview with Licensee, the facility failed to ensure R1's responsible party received a refund in the amount of $3000 based on facilitys own admission agreement in compliance with Title 22 which poses a potential health and safty risk to residents in care.
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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: 08/28/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/28/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 2