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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496803811
Report Date: 06/30/2023
Date Signed: 06/30/2023 01:12:20 PM


Document Has Been Signed on 06/30/2023 01:12 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: 5DATE:
06/30/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:51 AM
MET WITH:Nicholas Ray (Licensee)TIME COMPLETED:
01:27 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. There are residents with diagnosis of Dementia and Hospice Services.

LPA/Licensee initiated a tour of the facility around 9:55 am and made the following observations: Facility was a comfortable temperature and passageways were free from obstructions. Residents rooms were furnished per regulation. Extra hygiene products and linens were available. Facility has at least two days of perishable and one week of non-perishable foods which appeared to be of quality and stored per regulation.
Two fire extinguisher was last serviced December 2022. One carbon monoxide detector in the hallway was tested and properly working. Working auditory alarms are placed on all exits. Disinfectants and cleaning solutions were stored inaccessible to residents. Required postings were observed. Administrator Certificate for Nicholas Ray, 6027071740, expired on 6/23/2023. Administrator is currently on Department's pending List. Medications were centrally stored and locked.

At approximate 10:00am water temperature in bathrooms used by residents measured at 124.2 and 126.3 degrees F which are not all within the range of 105 to 120 degrees F allowed per regulation.

At approximate 10:15am LPA/Licensee observed fire/disaster drill have not been conducted within the last quarter.

LPA initiated file review at 10:30 am. LPA reviewed five residents files and two staff files. All residents files have a current medical assessment and care plans updated within the last 12 months. Staff records have current First Aid/CPR certificates, but they need additional 20 hours of required training. LPA/Licensee discussed previously agreement about additional staff needed to assist residents to meet their needs.

Continued on LIC809C...
SUPERVISOR'S NAME: Bethany MoellersTELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Marisol CuadraTELEPHONE: (707) 588-5078
LICENSING EVALUATOR SIGNATURE:
DATE: 06/30/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/30/2023
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 5


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
VISIT DATE: 06/30/2023
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Continued from LIC809...

At approximate 11:30am LPA/Licensee during medication review, it was observed that medication start dates records of two out of five residents (R1 & R2) were not entered into the Centrally Stored Medication Records including three out of ten medications for R1 as following: Tamsulosin HCL 0.4mg Cap, Pantoprazole Sod Dr 40mg and Atorvastatin 40mg tab. Three out of four medications for R2: Senna Plus 8.6-50mg, Hydrocodo/APAP 5-325mg and Acetaminophen 650mg ER. Licensee agreed to review and update start dates into the Centrally Stored Medication Records.

Licensee agreed to submit updates of the following documents by 7/21/23: Designation of Administrative Responsibility (LIC308), Personnel Report (LIC500), Copy of Liability Insurance
LIC 610 Emergency Disaster Plan (If changes) and Infection Control Plan (If changes)

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.

Exit interview was conducted with Licensee and a copy of this report was provided.

SUPERVISOR'S NAME: Bethany MoellersTELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Marisol CuadraTELEPHONE: (707) 588-5078
LICENSING EVALUATOR SIGNATURE:

DATE: 06/30/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/30/2023
LIC809 (FAS) - (06/04)
Page: 2 of 5
Document Has Been Signed on 06/30/2023 01:12 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: 06/30/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87303(e)(2)
Maintenance and Operation
(e) Water supplies and plumbing fixtures shall be maintained as follows: (2) Faucets used by residents for personal care such as shaving and grooming shall deliver hot water. Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degree F (41 degrees C) and not more than 120 degree F (49 degrees C).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA/Licensee observation and interview, Licensee did not comply with the section cited above in two out of two bathrooms used by residents in care water temperature was not within regulation, posing an immediate health, safety and personal rights risk to residents in care.
POC Due Date: 07/01/2023
Plan of Correction
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Licensee to ensure water temperature is within regulatory guidelines. Licensee will adjust water temperature within regulation. Licensee agrees to send self - certfication that water temperature will be monitored for one week to CCL by POC date.
Type A
Section Cited
CCR
87465(a)(6)
Incidental Medical and Dental Care Services
(6) When requested by the prescribing physician or the Department, a record of dosages of medications which are centrally stored shall be maintained by the facility.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA/Licensee observation, interview and record review, the licensee did not comply with the section cited above in two out of five residents in care which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 07/01/2023
Plan of Correction
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Licensee agreed to review medication records for all residents and will conduct medication training with staff. Licensee will submit a self-certification LIC9098 form along with training dates for staff 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: 06/30/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/30/2023
LIC809 (FAS) - (06/04)
Page: 3 of 5


Document Has Been Signed on 06/30/2023 01:12 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: 06/30/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.695(c)
Other Provisions
(c) A facility shall conduct a drill at least quarterly for each shift. The type of emergency covered in a drill shall vary from quarter to quarter, taking into account different emergency scenarios. An actual evacuation of residents is not required during a drill. While a facility may provide an opportunity for residents to participate in a drill, it shall not require any resident participation. Documentation of the drills shall include the date, the type of emergency covered by the drill, and the names of staff participating in the drill.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA's/Licensee observation, interview and record review, the licensee did not comply with the section cited above. Last disaster drill was conducted at least every quarter which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/21/2023
Plan of Correction
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Licensee agreed to conduct a quarterly disaster drill. Licensee will submit a current disaster drill conducted within the las quarter to clear the citation by POC due date.
Type B
Section Cited
CCR
87705(c)(3)
Care of Persons with Dementia
(c) Licensees who accept and retain residents with dementia shall be responsible for ensuring the following: (3) In addition to the on-the-job training requirements in Section 87411(d), staff who provide direct care to residents with dementia shall receive the following training as appropriate for the job assigned and as evidenced by safe and effective job performance:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA's/Licensee observation, interview and record review of staff files, the licensee did not comply with the section cited above in one out of two staff did not have 20 hours additional training, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/21/2023
Plan of Correction
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Licensee agreed to have staff take 20 hours of training and will send in proof of staff required training to LPA 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: 06/30/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/30/2023
LIC809 (FAS) - (06/04)
Page: 4 of 5


Document Has Been Signed on 06/30/2023 01:12 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: 06/30/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87705(c)(4)
Care of Persons with Dementia
(c) Licensees who accept and retain residents with dementia shall be responsible for ensuring the following: (4) There is an adequate number of direct care staff to support each resident's physical, social, emotional, safety and health care needs as identified in his/her current appraisal.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPAs observation and record review the facility failed to ensure adequate staffing to meet residents care needs which poses a potential health and safety risk to residents in care.
POC Due Date: 07/21/2023
Plan of Correction
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Licensee agrees to hire, train and submit a staffing schedule to ensure staffing is adequate to meet residents needs and there is not a lack of supervision, submit staff schedule to CCL 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: 06/30/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/30/2023
LIC809 (FAS) - (06/04)
Page: 5 of 5