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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496804195
Report Date: 12/04/2024
Date Signed: 12/04/2024 03:48:55 PM

Document Has Been Signed on 12/04/2024 03:48 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:TREE HAVEN ESTATE 1 LLCFACILITY NUMBER:
496804195
ADMINISTRATOR/
DIRECTOR:		MARIMBI, MARTHAFACILITY TYPE:
740
ADDRESS:359 TREE HAVEN LANETELEPHONE:
(707) 304-9106
CITY:KENWOODSTATE: CAZIP CODE:
95452
CAPACITY: 8CENSUS: 3DATE:
12/04/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:22 PM
MET WITH:Martha Marimbi, AdministratorTIME VISIT/
INSPECTION COMPLETED:
04:02 PM
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Licensing Program Analyst (LPA) Christi Coppo arrived unannounced to conduct a required Annual inspection and was greeted by Administrator Martha Marimbi.

At approximately 1:30pm LPA and Admin toured the building and grounds. The facility was found to be clean and at a comfortable temperature. LPA observed at least a 2 day supply of perishable and 7 day supply of non-perishable food. Food was found to be stored in a safe manner with open items covered. Cleaning supplies are stored in locked in outside laundry room. Kitchen drawer with sharp knives locked.

All bedrooms were equipped with lighting, night stand, and chest of drawers. All bedrooms were clean and in good repair. Extra hygiene products and linens were available. Resident bathroom had required bath mat and grab bar. Water temperature in sink accessible to residents in care measured at 118.9 degrees F in the bath off the kitchen, 112.4 degrees F in the cottage and 114.3 degrees F in room #2 which are all within the allowable range of 105 to 120 degrees F.

Fire extinguishers were last inspected 2/22/24. Smoke/Carbon Monoxide detectors located throughout the facility are hardwired and serviced annually by Santa Rosa Fire Equipment Inc, last serviced on 9/2024. Facility’s last quarterly disaster drills were conducted on 9/26/24. Facility has a backup generator for use during a power outage.

At approximately 2:00pm LPA conducted a review of 3 resident records. Resident (R1) did not have an appraisal on file (deficiency cited, see 809D).



Continued on 809C...
SUPERVISORS NAME: Victoria Bertozzi
LICENSING EVALUATOR NAME: Christi Coppo
LICENSING EVALUATOR SIGNATURE: DATE: 12/04/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/04/2024
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
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME: TREE HAVEN ESTATE 1 LLC
FACILITY NUMBER: 496804195
VISIT DATE: 12/04/2024
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Continued from 809...

At approximately 2:30pm LPA conducted review of 4 staff records. LPA reviewed training materials with Admin. Admin advised that the training materials used are videos inherited from the licensee and are dated 2011 or earlier. LPA observed some training materials to be printed training modules issued by Advanced Healthcare Studies, LLC but did not have a date of publication. LPA discussed either updating training materials to something current and pertinent or using an approved vendor to conduct staff training. Facility will submit pictures of updated materials to CCL if an approved vendor is not chosen. Facility will submit to CCL the pictures of the chosen materials or their selected approved vendor by 12/18/24.



At approximately 3:00pm LPA and Admin conducted a spot check of medication and medication records. Medication is centrally stored in a locked cabinet. Resident (R2) had two medications, Indapamide 2.5mg and FeroSul 325mg, not logged on the Centrally Stored Medication log (deficiency cited, see 809D)

Martha Marimbi Administrator Certificate 7018478740 expires 3/21/25.



Updated copies of the following documents were requested for facility file and are to be submitted to CCL within 30 days of this visit:

LIC500- Personnel Report
LIC308- Designation of Responsibility

Deficiencies cited from the California Code of Regulations, Title 22, Division 6 of California Regulation and the Health and Safety Code. Appeal rights given and discussed with Admin. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties.\

Exit interview conducted with Administrator and a copy of this report was given.

SUPERVISORS NAME: Victoria Bertozzi
LICENSING EVALUATOR NAME: Christi Coppo
LICENSING EVALUATOR SIGNATURE:

DATE: 12/04/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/04/2024
LIC809 (FAS) - (06/04)
Page: 2 of 4
Document Has Been Signed on 12/04/2024 03:48 PM - It Cannot Be Edited


Created By: Christi Coppo On 12/04/2024 at 03:23 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: TREE HAVEN ESTATE 1 LLC
FACILITY NUMBER: 496804195

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/04/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87465(h)(6)
87465 Incidental Medical and Dental Care (h) The following requirements shall apply to medications which are centrally stored: (6) The licensee shall be responsible for assuring that a record of centrally stored prescription medications for each resident is maintained for at least one year and includes

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA and Admin observation and record review, the licensee did not comply with the section cited above in that two [2] medications for R2 were not listed on the Centrally Stored Medication log, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 12/05/2024
Plan of Correction
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Facility to submit LIC9098 self-certifying all medications for all residetns on listed on their respective Centrally Stored Medication logs by plan of correction due date.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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4
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:Victoria Bertozzi
LICENSING EVALUATOR NAME:Christi Coppo
LICENSING EVALUATOR SIGNATURE:
DATE: 12/04/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/04/2024


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 12/04/2024 03:48 PM - It Cannot Be Edited


Created By: Christi Coppo On 12/04/2024 at 03:30 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: TREE HAVEN ESTATE 1 LLC
FACILITY NUMBER: 496804195

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/04/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87705(c)(6)
Care of Persons with Dementia
(c) Licensees who accept and retain residents with dementia shall be responsible for ensuring the following: (6) Appraisals are conducted on an ongoing basis pursuant to Section 87463, Reappraisals.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA and Admin observation and record review, the licensee did not comply with the section cited above inthat R1 did not have an appraisal on file, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/18/2024
Plan of Correction
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Facility to submit to CCL pictures of completed and signed by all parties appraisal for R1 by plan of corection due date.
Section Cited
Deficient Practice Statement
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4
POC Due Date:
Plan of Correction
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2
3
4
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:Victoria Bertozzi
LICENSING EVALUATOR NAME:Christi Coppo
LICENSING EVALUATOR SIGNATURE:
DATE: 12/04/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/04/2024


LIC809 (FAS) - (06/04)
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