496804179-1-9-2024-21-AS-DALO-CZBU25-20240109141121

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 496804179
Report Date: 01/09/2024
Date Signed: 01/09/2024 02:11:29 PM

Document Has Been Signed on 01/09/2024 02:11 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:	OLIVE TREE ASSISTED LIVING LLC		FACILITY NUMBER:	496804179
ADMINISTRATOR:	QUIJADA, CLAUDIA		FACILITY TYPE:	740
ADDRESS:	542 CARRIAGE CT		TELEPHONE:	(707) 522-6822
CITY:	SANTA ROSA	STATE: CA	ZIP CODE:	95403
CAPACITY:	6	CENSUS: 5	DATE:	01/09/2024
TYPE OF VISIT:	Prelicensing	UNANNOUNCED	TIME BEGAN:	09:45 AM
MET WITH:	Claudia Quijada-Applicant		TIME COMPLETED:	02:10 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analyst (LPA), Alviso conducted a pre-licensing inspection, at approximately 9:45am on 1/9/23, and met with Applicant Claudia Quijada; Claudia has a residential care for the elderly administrator certificate, #6060386740, expires 8/24/25. This application is a change of ownership, the facility is currently licensed as Green Meadows Living, #496803963. Facility has a fire clearance approval by the Santa Rosa County Fire Department for a total of six (6) capacity, four (4) non-ambulatory and two (2) bedridden-effective 11/16/2023. Bedridden rooms are #4 and #5 only. Applicant has applied for approval of a dementia plan of operation. Applicant has also applied for an approval of a hospice waiver for two (2). Applicant has submitted a required infection control plan, and a required emergency & disaster plan as part of their application packet. Facility will operate with an awake night staff, and Licensee will ensure sufficient 24/7 staffing at all times. Hot water was checked at 114.8 degrees Fahrenheit, which is within regulation. All exits were unobstructed in the home. All exit doors had auditory alarms and the alarms were working properly during the inspection. Fire extinguisher is serviced and tagged as required- expires 12/29/24. There are nine(9) smoke alarms that are also carbon monoxide detectors, all were working appropriately. Facility has a sufficient supply of food, perishable and non-perishable LPA observed sufficient supply of cleaners, paper products, hygiene products, and personal protective equipment (PPE). There is a large laundry room for storage, cabinets for laundry soap, and other cleaning items. Three is a large metal cabinet for the storage of resident medications; Applicant stated that the laundry room door is to be kept locked at all times to ensure residents don't have access to these stored items. Continued on LIC809C...

SUPERVISOR'S NAME: Hope DeBenedetti	TELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Dina Alviso	TELEPHONE: (707) 588-5082
LICENSING EVALUATOR SIGNATURE:	DATE: 01/09/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/09/2024

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 2

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: OLIVE TREE ASSISTED LIVING LLC	FACILITY NUMBER: 496804179
	VISIT DATE: 01/09/2024

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

The facility does have emergency food supplies, and emergency supplies, to meet the "72 hour shelter in place" requirements. There was sufficient lighting throughout the facility in resident rooms, common areas, bathrooms, and hallways. The grounds were free of any apparent hazards, and exits were clear. No bodies of water. No firearms. All bathrooms had grab bars for resident use. Postings noted to be current and in compliance with regulations. Facility does have a generator that can be used as needed for charging things like cell phones, batteries, lights/lanterns. There is a sign in and sign out log at the front door. All postings required were posted, and visible upon entry into the facility and during the facility tour.

LPA conducted a component III orientation with Applicant Claudia Quijada.

Pre-Licensing is complete and this facility has no apparent hazards to health and safety observed by the inspecting LPA, today, 1/9/24.

The facility sketches for the outside and inside have been revised to include changes that were made to the outside backyard property, and in the facility, an added room on the 2nd floor.

LPA notified application unit Analyst of physical plant changes; Fire clearance inspection has been requested by the application unit as required.

LPA will forward a copy of the completed inspection to the Application Analyst. Application Analyst will notify the applicant of the status of the application.

SUPERVISOR'S NAME: Hope DeBenedetti	TELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Dina Alviso	TELEPHONE: (707) 588-5082
LICENSING EVALUATOR SIGNATURE:	DATE: 01/09/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/09/2024

LIC809 (FAS) - (06/04)

Page: 2 of 2