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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496803811
Report Date: 07/30/2024
Date Signed: 07/30/2024 12:07:29 PM


Document Has Been Signed on 07/30/2024 12:07 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: 6DATE:
07/30/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:50 AM
MET WITH:Nicholas Ray (Licensee)TIME COMPLETED:
12:22 PM
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Licensing Program Analyst (LPA) Cuadra conducted an unannounced Annual Required Inspection and met with Licensee Nicholas Ray. Annual fees are current. Contact information was reviewed.

LPA/Licensee initiated a tour of the facility at 9:00 am. Facility passageways were free of obstruction.
Hot water temperature measured at 124.7 and 123.4 degrees F which is not within the range allowed per regulation (technical violation issued). Licensee adjusted water heater immediately. Smoke detectors and carbon monoxide was tested and operational. Two fire extinguishers were charged and serviced December 2023. Working auditory alarms are placed on all exits. Disinfectants and cleaning solutions were stored inaccessible to residents. Hygiene and bedding supplies were available. Non-perishable and perishable food supply met the minimum requirements. Required postings were observed. Medications and medication records were reviewed.

-No activities were conducted during LPA's visit. LPA/Licensee discussed the importance of having activities on a regular basis (technical violation was issued).
-Last disaster drill have not been conducted within the last quarter (technical violation was issued).
-Garbage cans located in the bathrooms did not have cover to prevent the transmission of communicable disease or odors (technical violation was issued).

LPA initiated file review at 10:00 am. LPA reviewed five residents files and three staff files. Residents medical assessments and needs service plans are current. One out of three staff do not have current First Aid/CPR certificates (technical violation issued). Two out of three staff (S1 & S2) needs 20 hours of additional required training. Administrator Certificate for Nicholas Ray, 6027071740, expires on 6/24/2025.
Continue on LIC809C...
SUPERVISOR'S NAME: Bethany MoellersTELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Marisol CuadraTELEPHONE: (707) 588-5078
LICENSING EVALUATOR SIGNATURE:
DATE: 07/30/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/30/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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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: 07/30/2024
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Continued from LIC809...

During tour of the facility LPA/Licensee observed a camera located on top of a dresser in shared resident's (R1 & R2) bedroom. LPA found that the camera was purchased by the Licensee with the purpose of motion sensor and does not recording nor auditory device to alert staff during overnight hours. LPA/Licensee discussed the need for an exception in order to continue using the camera in R1's & R2's bedroom as it is a private space and potential violation of resident rights. Licensee removed camera immediately and agreed to review with both resident's family and submit an exception letter request to CCLD along with appropriate documentation if they are in agreement or replace it with a motion detector device. Otherwise, the licensee agreed to don't install them back to the shared bedroom. The Department to review and return at a later date. Also, there are cameras located in common areas and resident's admission agreement were not updated reflecting the use of cameras without audio in common areas.

Licensee to submit updates of the following documents by 8/16/2024: Designation of Administrative Responsibility (LIC308), Personnel Report (LIC500) and copy of liability Certificate.

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 conducted with Licensee and copy of this report was given.

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

DATE: 07/30/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/30/2024
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 07/30/2024 12:07 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: 07/30/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.625(b)(2)
Other Provisions
(2) In addition to paragraph (1), training requirements shall also include an additional 20 hours annually, eight hours of which shall be dementia care training, as required by subdivision (a) of Section 1569.626, and four hours of which shall be specific to postural supports, restricted health conditions, and hospice care, as required by subdivision (a) of Section 1569.696. This training shall be administered on the job, or in a classroom setting, or both, and may include online training.

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 in two out of three staff do not have additional 20 hours annually, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/16/2024
Plan of Correction
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Licensee agrees to have staff complete training and send to CCL self-certification form (LIC9098) by POC due date to clear deficiency.
Type B
Section Cited
CCR
87468.1(a)
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:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPAs interview and observation the facility failed to ensure R1 & R2's personal rights are protected due to the camera with visual placed in shared R1's & R2's room which poses a potential health and safety risk to residents in care.
POC Due Date: 08/16/2024
Plan of Correction
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Licensee agrees to contact responsible party to remove or sign letter requesting use of cameras on R1's & R2's bedroom. Licensee will submit exception request or LIC9098 self-certifying that cameras won't be installed in shared bedroom to CCL by POC due date 8/16/2024.
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: 07/30/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/30/2024
LIC809 (FAS) - (06/04)
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