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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496804179
Report Date: 01/15/2025
Date Signed: 01/15/2025 02:52:57 PM

Document Has Been Signed on 01/15/2025 02:52 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
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME:OLIVE TREE ASSISTED LIVING LLCFACILITY NUMBER:
496804179
ADMINISTRATOR/
DIRECTOR:		QUIJADA, CLAUDIAFACILITY TYPE:
740
ADDRESS:542 CARRIAGE CTTELEPHONE:
(707) 522-6822
CITY:SANTA ROSASTATE: CAZIP CODE:
95403
CAPACITY: 6CENSUS: 5DATE:
01/15/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:00 AM
MET WITH:Claudia Quijada-AdministratorTIME VISIT/
INSPECTION COMPLETED:
03:00 PM
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Licensing Program Analyst (LPA) Alviso conducted a Required- 1 Year visit, on 1/15/25 at approximately 10:00am, and met with Licensee/Administrator Claudia Quijada. There are currently five (5) residents in care, and one (1) resident is on hospice services.

Facility has an approved dementia plan of operation. There is an approved hospice waiver for two (2) residents. Facility has an infection control plan as required. Facility has an emergency disaster plan as required.

Facility has a fire clearance approval for a total of six non-ambulatory, of which two (2) may be bedridden. All locks on exterior gates are approved. The self latching fire exit gate is never to have a lock on it. The facility's last fire drill and evacuation drill was conducted 10/15/24 & 7/1/24. The facility does have emergency food, water, and miscellaneous supplies to meet the "72 hour shelter in place" requirements.

LPA reviewed five (5) resident files; Resident files were complete.

LPA reviewed five (5) staff files. LPA reviewed staff training. All five(5) staff have criminal record clearance, and are associated as required. All staff had required training. All staff had current First Aid and CPR Certification.

Hot water checked at 116.6 degrees Fahrenheit, which is within regulation. All exits were free and clear of obstruction. Fire extinguisher was serviced and tagged as required. Smoke alarms that are also carbon monoxide detectors were working properly during the inspection. The backyard has outside cement patio, with furnishings for resident use, including areas providing shade for residents as needed. The facility was at a comfortable temperature for residents in care; Residents were observed to be watching television and engaging with the staff during the inspection.
Continued on LIC809C...
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Dina Alviso
LICENSING EVALUATOR SIGNATURE: DATE: 01/15/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/15/2025
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
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME: OLIVE TREE ASSISTED LIVING LLC
FACILITY NUMBER: 496804179
VISIT DATE: 01/15/2025
NARRATIVE
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LPA observed sufficient supply of food, perishable and non-perishable, for resident meals/snacks. Facility had sufficient furnishings for residents in care. The facility has sufficient lighting in all rooms, bathrooms, and common areas, including night lights.

There was a sufficient supply of hygiene products, cleaning supplies, personal protective equipment (PPE), and paper products for use as needed. All bathrooms had grab bars, and non-slip mat/flooring for bathing/showering as needed. All medications were stored/locked and inaccessible to residents in care. All cleaners/disinfectants were locked up and inaccessible to residents in care.

LPA is requesting the following documents be updated and submitted by 2/15/2025:

LIC308 - Designation of Administrator Responsibility
LIC500 - Personnel Report
LIC610E- Emergency Disaster Plan (ensure to review and update as needed/required)
LIC400 Handling of Client Cash Resources (include copy of surety bond if handling cash)
Copy of Current Liability Insurance
Copy of current Administrator Certificate

The following deficiency was observed by the LPA during the inspection:

Per file reviews and interviews, the Licensee has not submitted required incident reports/death reports; There is no proof that these reports were submitted to the licensing office, per file reviews. This deficiency will be cited, 87211-Reporting Requirements(a)(1)(2)-Each licensee shall furnish to the licensing agency such reports as the Department may require, including, but not limited to, the following: A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence of any of the events specified in (A) through (D). This report shall include the resident's name, age, sex and date of admission; date and nature of event; attending physician's name, findings, and treatment, if any; and disposition of the case, see LIC809D.

Continued on LIC809C..
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Dina Alviso
LICENSING EVALUATOR SIGNATURE:

DATE: 01/15/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/15/2025
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
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME: OLIVE TREE ASSISTED LIVING LLC
FACILITY NUMBER: 496804179
VISIT DATE: 01/15/2025
NARRATIVE
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LPA observed numerous items stored in the food pantry that were open and not stored appropriately to ensure no contamination of the food items, observed were bags of flour, rice, crackers, chocolate mix, and other miscellaneous items. LPA discussed Food Service regulation with the Administrator in regards to storage of food items. This deficiency will be cited, General Food Service Requirements 87555(b)(28)- All food shall be protected against contamination. Contaminated food shall be discarded immediately upon discovery, see LIC809D.

Deficiencies cited from the California Code of Regulations, Title 22, Division 6 of California Regulation. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties.



Appeal rights given to the Administrator/Licensee.
Exit interview conducted with Administrator/Licensee Claudia Quijada.
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Dina Alviso
LICENSING EVALUATOR SIGNATURE:

DATE: 01/15/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/15/2025
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 01/15/2025 02:52 PM - It Cannot Be Edited


Created By: Dina Alviso On 01/15/2025 at 02:17 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: OLIVE TREE ASSISTED LIVING LLC
FACILITY NUMBER: 496804179

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/15/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87555(b)(28)
General Food Service Requirements
(b) The following food service requirements shall apply: (28) All food shall be protected against contamination. Contaminated food shall be discarded immediately upon discovery.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above in [count] out of [total count] [(objects) (persons)] [identifiers] which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 01/16/2025
Plan of Correction
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Licensee to ensure that all food is stored and maintained in an appropriate manner in order to have no contamination of the food items. Submit plan of correction in how the facility will ensure compliance with this regulation. Submit what was completed to bring the facility into compliance. Hold an in-service training regarding food storage with all staff. Submit proof of training by 1/24/25. POC due 1/16/25.
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 Moellers
LICENSING EVALUATOR NAME:Dina Alviso
LICENSING EVALUATOR SIGNATURE:
DATE: 01/15/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/15/2025


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 01/15/2025 02:52 PM - It Cannot Be Edited


Created By: Dina Alviso On 01/15/2025 at 02:21 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: OLIVE TREE ASSISTED LIVING LLC
FACILITY NUMBER: 496804179

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/15/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87211(a)(1)(2)
87211(a)(1)(2) Reporting Requirements-Each licensee shall furnish to the licensing agency such reports as the Department may require, including, but not limited to, the following: A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence of any of the events specified in (A) through (D). This report shall include the resident's name, age, sex and date of admission; date and nature of event; attending physician's name, findings, and treatment, if any; and disposition of the case. Occurrences, such as epidemic outbreaks, poisonings, catastrophes or major accidents which threaten the welfare, safety or health of residents, personnel or visitors, shall be reported within 24 hours either by telephone or facsimile to the licensing agency and to the local health officer when appropriate.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on Based on file reviews and interview with Licensee, the Licensee has not submitted required incident reports/death reports as required; There have been resident reports that licensing should have been notified of. There was no proof able to be provided that these reports were submitted as required, the licensee did not comply with the section cited above which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 01/31/2025
Plan of Correction
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Licensee to ensure that all reports, incidents and deaths, that need to be submitted to licensing are completed as required and submitted within regulation time frame. Submit all reports, incidents/deaths as discussed during the inspection that were not received by Licensing Department. POC due 1/31/25.

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 Moellers
LICENSING EVALUATOR NAME:Dina Alviso
LICENSING EVALUATOR SIGNATURE:
DATE: 01/15/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/15/2025


LIC809 (FAS) - (06/04)
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