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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496803811
Report Date: 05/27/2022
Date Signed: 05/27/2022 02:55:22 PM


Document Has Been Signed on 05/27/2022 02:55 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:RAY, NICHOLASFACILITY TYPE:
740
ADDRESS:604 LIVE OAK AVENUETELEPHONE:
(707) 823-7277
CITY:SEBASTOPOLSTATE: CAZIP CODE:
95472
CAPACITY:6CENSUS: 3DATE:
05/27/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:58 PM
MET WITH:Nicholas Ray (Licensee)TIME COMPLETED:
03:10 PM
NARRATIVE
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Licensing Program Analyst (LPA) Cuadra arrived unannounced to conduct an Annual Required inspection and met with Licensee Nicholas Ray. LPA/Licensee reviewed PIN 22-07, 22-09, 22-13, 22-15 and 22-16.

LPA arrived at the facility and had their temperature checked and logged into a sign-in sheet. However, the staff did not ask screening questions to LPA. LPA observed that facility has posters on the front door indicating visitors about updated visitor's policy to protect residents in care. Once inside the facility, LPA observed that staff was not wearing masks. LPA/Licensee discussed the importance to follow their Mitigation Plan that it was approved on 1/3/22. At approximate 1:00pm LPA/Licensee observed that one out of two bathrooms was being remodel. Per Licensee, he wasn't aware that CCL was required to be notified prior to any remodelation to the facility. LPA/Licensee conducted a walk-through of the facility and observed Covid-19 posters that included hand washing signs. Hand sanitizer were observed in the common area of the facility. Facility bathroom are kept stocked with hand hygiene and paper products. Commonly touched surfaces are disinfected at least two times a day. Facility is able to accommodate a single room for each resident that needs to isolate and is able to serve meals and deliver medications. Facility staff have been trained on PPE protocols and N-95 fit tested. Residents are being monitored daily and results are documented. Facility maintains a 30 day supply of medication. Facility has a 100% vaccination rate and received boosters for staff and residents. Residents do not typically wear a mask while in the facility, but they do wear masks when in the community. On 12/17/21 LPA conducted a Case Management to address staffing issues. However, during today's visit Licensee informed LPA that there is only two staff in the facility schedule including the Licensee. Further actions will be reviewed by the Department.
Licensee agreed to provide updates of the following by 6/3/22: Designation of Administrative Responsibility (LIC308), Personnel Report (LIC500), Liability insurance and Emergency Disaster Plan (LIC610E).
Deficiencies cited from the California Code of Regulations, Title 22, Division 6 of California Regulation. Appeal rights given. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties.
SUPERVISOR'S NAME: Bethany MoellersTELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Marisol CuadraTELEPHONE: (707) 588-5078
LICENSING EVALUATOR SIGNATURE:
DATE: 05/27/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/27/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 3


Document Has Been Signed on 05/27/2022 02:55 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 05/27/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87468.1(a)(2)
Personal Rights of Residents in all Facilities
(a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (2) To be accorded safe, healthful and comfortable accommodations, furnishings and equipment.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA’s observation, record review and interviews with Licensee did not ensure that staff was wearing a mask and staff daily screening results are documented as reflected in facility's mitigation plan and current CCL requirements. This poses an immediate risk to the health, safety and personal rights to the residents in care.
POC Due Date: 05/28/2022
Plan of Correction
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Licensee will ensure Personal Rights of residents are maintained. Licensee agrees to submit self-certification (LIC9098) as a proof that all staff has been reminded about mask requirement to CCL by POC due date.
Type A
Section Cited
CCR
87411(a)
Type A 87411 Personnel Requirements (a) Facility personnel shall at all times be sufficient in numbers & competent to provide the services necessary to meet resident needs…This requirement has not been met as evidence by:

Deficient Practice Statement
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Based on observations, records review and interviews with Licensee did not ensure that staff on duty was sufficient to meet the needs of residents in care. Per Licensee, there are only two staff including him to provide services to residents in care which poses an immediate risk to the health and safety of residents in care.
POC Due Date: 05/28/2022
Plan of Correction
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Licensee agreed to submit a written plan in how the facility will ensure that resident’s needs are being met daily and Personnel Report (LIC500) to CCL by POC due date.

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Bethany MoellersTELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Marisol CuadraTELEPHONE: (707) 588-5078
LICENSING EVALUATOR SIGNATURE:
DATE: 05/27/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/27/2022
LIC809 (FAS) - (06/04)
Page: 2 of 3


Document Has Been Signed on 05/27/2022 02:55 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 05/27/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87211(a)(1)

Type B 87211 Reporting Requirements (a) Each licensee shall furnish to the licensing agency such reports as the Department may require…(1) A written report shall be submitted to the licensing agency & person responsible for the resident within 7 days of the occurrence of any of the events…This requirement has not been met as evidence by:
Deficient Practice Statement
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Based on LPA’s records review and interviews conducted with Administrator did not ensure that CCL was notified of one out of two bathrooms used by residents in care were being remodel which poses a potential health & safety risk to residents in care.
POC Due Date: 06/03/2022
Plan of Correction
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Licensee to ensure all incidents that threaten the health & safety of residents are reported to CCL per regulation. Licensee to review regulation and will submit LIC90998 self-certification that the regulation was reviewed by POC due date.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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.
SUPERVISOR'S NAME: Bethany MoellersTELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Marisol CuadraTELEPHONE: (707) 588-5078
LICENSING EVALUATOR SIGNATURE:
DATE: 05/27/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/27/2022
LIC809 (FAS) - (06/04)
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