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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496804028
Report Date: 10/14/2022
Date Signed: 10/14/2022 09:25:41 AM


Document Has Been Signed on 10/14/2022 09:25 AM - 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:TREEHOUSE SENIOR LIVINGFACILITY NUMBER:
496804028
ADMINISTRATOR:PATEL, DHARMISTHABENFACILITY TYPE:
740
ADDRESS:1879 ALAN DRIVETELEPHONE:
(707) 665-5624
CITY:PENNGROVESTATE: CAZIP CODE:
94951
CAPACITY:10CENSUS: 6DATE:
10/14/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
08:00 AM
MET WITH:Dharmisthaben Patel - LicenseeTIME COMPLETED:
09:30 AM
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Licensing Program Analyst (LPA) Hansen arrived unannounced to conduct a Case Management inspection and met with Licensee Darmi Patel & staff Pamela Lopez.

LPA is following up regarding a self-reported Incident Report received on October 10, 2022 regarding an incident that occurred on 10/9/22 at 3:40 am where resident, R1 slipped and fell while getting out of bed. According to caregiver R1 then got up and used the bathroom, stated is fine and caregiver helped R1 back to bed. Later that morning R1 was observed with bruising on right side of head. The following day R1 was feeling weak and dizzy and refused breakfast. Appropriate parties contacted and R1 went to the hospital. No other details were provided. LPA was unable to contact facility and has since obtained other contact information. During today's inspection LPA obtained discharge documents and was informed R1 was brought back to the facility same day as incident with no concussion or restrictions and no change in care or hospice recommendation.

No deficiencies cited during today's inspection.

SUPERVISOR'S NAME: Bethany MoellersTELEPHONE: (707) 588-5026
LICENSING EVALUATOR NAME: Shannan HansenTELEPHONE: 707-588-5026
LICENSING EVALUATOR SIGNATURE:
DATE: 10/14/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/14/2022
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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