496803811-7-30-2024-21-AS-BMOS-D7PT6W-20240731142746

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 496803811
Report Date: 07/30/2024
Date Signed: 07/30/2024 11:48:20 AM

Unsubstantiated

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
05/08/2024 and conducted by Evaluator Marisol Cuadra

COMPLAINT CONTROL NUMBER: 21-AS-20240508100012

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: 6	DATE:	07/30/2024
		UNANNOUNCED	TIME BEGAN:	09:33 AM
MET WITH:	Nicholas Ray (Licensee)		TIME COMPLETED:	12:03 PM

ALLEGATION(S):

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-Personal Rights

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Cuadra arrived unannounced to conduct a complaint investigation and deliver findings regarding the above allegations and met with Licensee Nicholas Ray.

The Department received an allegation of personal rights. Per Reporting party, the staff (unknown name was provided) often yells at resident (R1) when they ask for assistance. Additional concerns such as R1 has request to go to the bank and for a medical call alert due to fear of falling, but has been denied the assistance. LPA conducted an unannounced visit on 5/14/24 and confidential interviews were conducted with staff (S1) and residents (R1, R2 & R3) in care. Based on interviews, there were no concerns been raised related with care and supervision provided by the facility staff including any incident of yelling or any transportation arrangement issues.

Continue 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: 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.

LIC9099 (FAS) - (06/04)

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Control Number 21-AS-20240508100012

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: 07/30/2024

NARRATIVE

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Continued from LIC9099...

During records review, LPA have reviewed R1’s physician’s report dated 3/14/24, where it was revealed that R1 does not have any cognitive issues and there are some communication challenges that requires additional time for staff to understand R1’s speech resulting in R1 experiencing at times some episodes of anxiety.

However, during the investigation there was no information or concern that could revealed that any of the incidents above mentioned have happened at a prior date. A finding that the complaint allegation of personal rights is unsubstantiated meaning that although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegation is UNSUBSTANTIATED.

SUPERVISOR'S NAME: Bethany Moellers	TELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Marisol Cuadra	TELEPHONE: (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

LIC9099 (FAS) - (06/04)

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