Live Oak Rest Home

Allegation investigated: -Licensee does not prevent resident from starting fires in the facility. -Licensee does not ensure resident is bathed. -Licensee retains resident whose presence present risk to the safety of other residents.

Licensing Program Analyst (LPA) Cuadra arrived unannounced to conduct a complaint investigation and delivered findings regarding the allegation listed above and met with Nicholas Ray, Licensee. The Department received an allegation of licensee does not prevent resident from starting fires in the facility. According to complainant, R1 has started multiple fires in the facility, which is dangerous because most of the residents are non-ambulatory, where there is no nighttime care in the facility and R1 may end up killing everyone in the facility with fire. Co-complainant reports there is one report of an attempted fire at the facility. Based on interviews conducted with facility staff (S1, S2 & S3) including the Licensee, it was revealed that R1 will kept coming with several lighters and matches, saying weird things, ignited some of the matches to light things on fire in their room, they will bring leaves inside their room, keep them in a bowl trying and attempted to set shared bathroom located in the hallway on fire back in April, photography were provided to LPA, where it was observed fire damage in residents' bathroom. Continued on LIC9099C... Substantiated Continued from LIC9099... Based on records review, it was confirmed that four out of five residents (R1, R2, R3 & R4) are non-ambulatory. The licensee provided three written statements from residents’ responsible parties as supporting evidence because residents in care won't be able to provide any statements due to their cognitive condition. Incidents received from R4’s responsible party dated 6/1/26, R5’s responsible parties dated 5/30/26, staff (S1 & S2). LPA obtained police records (case #26-0379) confirming that R1 was placed on 5150 holds due to mental health issues when they attacked a facility staff (S1) with a knife. On 3/30/26, LPA instructed the licensee to provide additional staffing to ensure the health and safety of the residents in care, but based on LIC500 Personnel Report dated 5/1/26, the licensee did not provide additional staffing to ensure the health and safety of the residents in care. LPA will address observation of R1 in case management due to licensee did not notify R1’s physician after observing a significant change of condition and documenting it in R1’s care plan dated 3/1/26. The preponderance of evidence standard has been met; therefore, the above allegation is found to be SUBSTANTIATED. California Code of Regulations, (Title 22, Division 6, Chapter 8), is cited on the attached LIC 9099D. Appeal Rights Given. The preponderance of evidence standard has been met; therefore, the above allegation is found to be SUBSTANTIATED. California Code of Regulations, (Title 22, Division 6, Chapter 8), is cited on the attached LIC 9099D. Appeal Rights Given. Regarding allegation of licensee does not ensure resident is bathed. According to reporting parties, R1 apparently has not bathed in months and has dirty hair and body odor. Based on records review, R1’s physician report dated 6/18/25 indicates that R1 was able to perform all activities of daily living including bathing, dressing and grooming for themselves. R1’s care plan dated 3/1/26 instructs staff to observe R1 for cleanliness daily. Based on interviews conducted with staff (S1, S2 & S3) it was confirmed that R1 was independent to perform their activities of daily living, but after facility staff noticed that R1 was experiencing a decrease in their ability to care for their personal appearance by having dirty hair and body odor. Although the significant changes of R1’s mental condition were documented by the licensee who updated their care plan on 3/1/26, but the licensee did not send R1 for medical evaluation with their physician to obtain an updated physician report (LIC602) as stated in R1’s update care plan. Continued into LIC9099C... Continued from LIC9099C... Although it was documented and observed by staff that R1’s hygiene care needs were increasing, staff did not assist R1 with bathing needs resulting in R1’s hygiene needs not being met. The preponderance of evidence standard has been met; therefore, the above allegation is found to be SUBSTANTIATED. California Code of Regulations, (Title 22, Division 6, Chapter 8), is cited on the attached LIC 9099D. Appeal Rights Given. The preponderance of evidence standard has been met; therefore, the above allegation is found to be SUBSTANTIATED. California Code of Regulations, (Title 22, Division 6, Chapter 8), is cited on the attached LIC 9099D. Appeal Rights Given. An allegation about the licensee retains resident whose presence presents risk to the safety of other residents. Per reporting party, resident (R1) needs a higher level of care than this facility can provide and because of this it is a danger to themselves and to other residents. Co-complainant alleges that R1 should be relocated to a facility that is better suited to care for them and protect the other residents and staff. After an incident that occurred on 5/29/26 when R1 attacked facility employee with a cutting board, knife (case #26-0379) and was placed on a 5150 hold as a result of a mental health issue. At 9pmd on records review, an incident report submitted to the Department was found dated 3/30/26 notifying that on 3/21/26 at approximately 9pm caregiver heard R1’s roommate (R2) in distress, when the staff entered the room observed R1 trying to pull R2 out of their bed, struck the staff knocking them down. However, LPA instructed the licensee to provide additional staffing to ensure the health and safety of the residents in care, which it was not provided by the licensee as reviewed in the personnel report (LIC500) dated 5/1/26. On 4/1/26, the licensee submitted an unlawful 30-day eviction issued to R1 due to their behaviors that resulted in R1’s hospitalizations, but Licensee agreed to not proceed with eviction process, accepted R1 back to the facility and sent R1 again for medical evaluation if any further incidents happened. However, LPA instructed the licensee to provide additional staffing to ensure the health and safety of the residents in care, which it was not provided by the licensee as reviewed in the personnel report (LIC500) dated 5/1/26. The preponderance of evidence standard has been met; therefore, the above allegation is found to be SUBSTANTIATED. California Code of Regulations, (Title 22, Division 6, Chapter 8), is cited on the attached LIC 9099D. Appeal Rights Given. Continued from LIC9099A... Although a printout from their physician indicates that R1 was prescribed Celexa 40mg one tablet every day for 90 days since 4/14/26, R1’s centrally stored medication and destruction records and medication administration record (MAR) indicate compliance with prescribed medication dates and dosages. Furthermore, daily medicine schedule confirming that R1 was taking citalopram 40 mg with breakfast and quetiapine medication marked as taken at bedtime. Based on interviews conducted with the Licensee, R1 was taking Seroquel 50mg at bedtime after increasing the medication from 25mg every six hours because that didn’t do anything to help to reduce R1’s aggressive behaviors. Based on interviews conducted with the licensee and staff (S1, S2 & S3), licensee is the designated person that pre pours medications to be given to the residents in care, which is a violation of Title 22 regulations. LPA will address a case management centrally stored medication management about transferring medications between containers. A finding that the complaint allegation of licensee mismanages residents’ medication is unsubstantiated means that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is UNSUBSTANTIATED. Another allegation refers to licensee does not provide adequate care and supervision, resulting in resident eloping multiple times. Per Reporting party, R1 elopes from the facility three times a day and walks across the street through moving traffic, goes to an African dance event and takes off their clothing in public, and walks around town in underwear but no pants. Co-complainant stated that R1 would leave the facility on foot and walk through moving traffic. Based on records review, R1’s physician report dated 6/18/25 indicates that R1 was able to leave the facility unassisted, R1 walks long distances and has never become confused about how to return to their location. However, after incident that occurred on 3/21/26 where R1 was sent to the emergency room due to aggressive behavior towards another resident (R2), licensee updated R1’s care plan indicating that facility staff recommended to R1’s responsible party that R1 was not allowed to walk around town freely as it was not safe for R1 to do so, but an updated physician report was not requested by the licensee after observing a significant change of condition and care plan was not signed by R1’s responsible party. LPA will address observations relating to change of condition of R1 in case management. A finding that the complaint allegation licensee does not provide adequate care and supervision, resulting in resident eloping multiple times is unsubstantiated means that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is UNSUBSTANTIATED. Continued on LIC9099C... Continued from LIC9099C...Regarding allegation of licensee does not ensure resident is appropriately dressed. The reporting party and co-complainant alleges that R1 who has a diagnosis of dementia elopes the facility goes to an African dance event and takes off their clothing in public and walks around town in underwear but no pants. Based on records review, R1’s physician report dated 6/18/25 indicates that R1 was able to perform all activities of daily living and was able to leave the facility unassisted. On 3/1/26, the licensee updated R1’s care plan indicating the need to not allow R1 to go out unassisted due to safety, but changes noticed by facility staff were not brought to R1’s physician for further evaluation. LPA conducted interviews with staff (S1, S2, S3) who stated that they are unaware that R1 was taking their clothes off in public, but they revealed that R1 will go to the laundry area, take off their clothes in the facility in front of others, but when they attempted to assist them to put their clothes back on or provide a cloth to cover them up, R1 will attempt to hit, kick, push or swings at staff, which it was documented in R1’s updated care plan dated 3/1/26. Although complainant states that R1 was not appropriately dressed, records review and interviews conducted with staff it is unclear to determine if R1 will take off their clothing in public when they went outside of the facility. LPA will address observation of R1 in case management due to licensee failed to notify R1’s physician after a significant change of condition was documented in R1’s care plan dated 3/1/26. The finding that the complaint allegation licensee does not ensure resident is appropriately dressed is unsubstantiated means that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is UNSUBSTANTIATED. About allegation of licensee does not provide nighttime care to residents. The reporting party alleges that when incidents of R1 attempted to start fires at the facility there was no nighttime care in the facility, so if a resident needs help at night, they will not get it. On 7/21/26, LPA conducted 10-day visit to the facility, made observations, reviewed records and conducted interviews with residents and staff. Based on LPA’s observations on 7/21/26, LPA arrived at the facility approximately 8:47am, rang the bell as the morning shift was arriving too, but nobody came to open the door, arriving staff granted entry to the facility to LPA by the side door, LPA went around the facility, but no staff was present, licensee who resides in the back building arrived within five minutes, when LPA inquired about who was providing care and supervision to residents, licensee responded me, I worked the night shift, but I just went to the little house for a moment. Based on records review, an incident report submitted to the Department dated 3/30/26 confirms that there was a night staff present during incident that occurred on 3/21/26 at approximately 9pm when staff (S2) heard R1’s roommate (R2) in distress, when S2 entered the room observed R1 trying to pull R2 out of their bed, struck S2 knocking them down. Continues on LIC9099C... Continued from LIC9099C...Also, the facility provided LIC500 Personnel report confirming night shift coverage for at least two different staff. LPA conducted interviews with staff (S1, S2 & S3) and residents (R1, R2 & R3) in care did not provide any supporting evidence about lack of care and supervision to residents in care during nights. LPA was unable to obtain any additional information from reporting party, such as dates, residents involved or any specific information to support this allegation. A finding that the complaint allegation licensee does not provide nighttime care to residents is unsubstantiated means that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is UNSUBSTANTIATED. Another allegation of licensee yells at residents. Per Reporting party and co-complainant stated that licensee often yells at residents that he is angry at them, especially R1. Based on LPA’s interviews conducted with staff (S1, S2 & S3) and residents (R2, R3 & R4) in care, LPA learned that there are no instances of licensee yelling at residents in care. Based on records review of residents’ physician reports and care plans indicate that two out of three residents (R2 & R3) have a diagnosis of dementia, but records review did not reveal any evidence to support above allegation. Although allegation is unsubstantiated, it was revealed through interviews with staff that staff (S1) has been observed speaking loudly to residents in care, but LPA was able/unable to obtain proof that S1 yells at residents in care? A finding that the complaint allegation of licensee yells at residents is unsubstantiated means that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is UNSUBSTANTIATED. Last allegation of licensee does not prevent resident from eating spoiled food. The reporting party noticed that R1 has a refrigerator full of rotten, spoiled food that licensee does not prevent them from eating. Based on records review, there was no documentation of R1’s personal fridge located in their room, but according to interviews conducted by LPA with staff (S1, S2 & S3), R1 tended to eat only organic food items that they will obtain through food banks or on their own. Although R1’s care plan dated 3/1/26 instructs staff to observe R1 for food intake daily. Based on interviews conducted with staff (S1, S2 & S3) it was confirmed that R1 will maintain spoiled food items in their personal fridge without staff doing anything about it because they were scared that R1 could hit them, but it is unclear to determine based on verbal statements if facility staff have observed R1 eating spoiled food. A finding that the complaint allegation of licensee does not prevent resident from eating spoiled food is unsubstantiated means that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is UNSUBSTANTIATED.the state’s words, verbatim · CDSS document, Aug 11, 2026 · control 21-AS-20260604152001

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87461(a)(5) · Plan of correction due date: Aug 12, 2026

87461 Mental Condition:(a) The facility shall determine the amount of supervision necessary by assessing the mental status of the prospective resident to determine if the individual:(5) has a documented history of behaviors which may result in harm to self or others. This requirement is not met as evidence by: Based on records reviewed and interviews conducted with facility staff, Licensee did not ensure the necessary supervision was given, resulting in R1 attempted to set the bathroom on fire, which poses an immediate risk to the health and safety of residents in care.the state’s words, verbatim · CDSS document, Aug 11, 2026

Plan of correction: Licensee agrees to submit a written plan describing how the facility will ensure residents’ needs are met and the proper supervision is provided. Plan should address the re-appraisal process for changes in condition including inappropriate interactions with residents and staff. Written plan will be submitted to CCL by POC due date of 8/12/26.

From the deficiency page — Deficiency type: Type A · Section cited: HSC 1569.269(a)(6) · Plan of correction due date: Aug 12, 2026

§1569.269 Enumerated rights; severability (a) Residents of RCFE shall have all of the following rights: (6) To care, supervision, and services that meet their individual needs and are delivered by staff that are sufficient in numbers, qualifications, and competency to meet their needs. This requirement has not been met as evidence by: Based on records review and interviews conducted with staff, it was revealed that the licensee did not ensure that R1’s hygiene meets were being met, which poses an immediate risk to the health and safety of residents in care.the state’s words, verbatim · CDSS document, Aug 11, 2026

Plan of correction: Licensee agrees to submit a written plan describing how the facility will ensure residents’ needs are met including activities of daily living including bath. Written plan will be submitted to CCL by POC due date of 8/11/26.

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87411(a) · Plan of correction due date: Aug 12, 2026

87411 Personnel Requirements – General (a) Facility personnel shall at all times be sufficient in numbers, & competent to provide the services necessary to meet resident needs…The licensing agency may require any facility to provide additional staff whenever it determines through documentation that the needs of the particular residents, the extent of services provided, or the physical arrangements of the facility require such additional staff for the provision of adequate services. This requirement has not been met as evidence by: Based on LPA’s records review and interviews with facility staff, the licensee failed to hire additional staff to ensure the safety of the residents in care after learning of R1’s significant change of mental condition resulting in R1 attempted to pull their roommate R2 out of their bed at night on 3/30/26 which poses an immediate risk to the health and safety of the residents.the state’s words, verbatim · CDSS document, Aug 11, 2026

Plan of correction: Licensee agrees to submit a written plan describing how the facility will ensure residents’ safety when a resident experiences a significant change in mental condition and adequate supervision is provided. Written plan will be submitted to CCL by POC due date of 8/11/26.

Type of visit: Case Management - Deficiencies

Licensing Program Analyst (LPA) Cuadra arrived unannounced to the facility to conduct a case management visit to cite deficiencies discovered during a complaint investigation and met with Licensee, Nicholas Ray. LPA learned through reviewed records and interviews with staff (S1, S2 & S3), the licensee noticed a significant change in R1’s mental condition, updated their care plan as of 3/1/26 but failed to notify R1’s physician for further evaluation. Additionally, licensee is the designated person that pre pours medications to be given to the residents in care, which is a violation of Title 22 regulations. During today’s visit, LPA is addressing observation of R1 after a significant change of condition was observed, documented and centrally stored medication management about transferring medications between containers. Deficiencies cited from the California Code of Regulations, Title 22, Division 6 of California Regulation. Appeal rights given. Failure to correct the deficiency and/or repeat deficiencies within a 12-month period may result in civil penalties. Licensee refused to sign the LIC809 and LIC809D forms acknowledging the findings. LPA printed forms and left them with the Licensee.the state’s words, verbatim · CDSS document, Aug 11, 2026

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87466 · Plan of correction due date: Aug 12, 2026

87466 Observation of the Resident The licensee shall ensure that residents are regularly observed for changes in physical, mental, emotional & social functioning…When changes such as…deterioration of mental ability or a physical health condition are observed, the licensee shall ensure that such changes are documented & brought to the attention of the resident's physician and the resident's responsible person, if any…This requirement has not been met as evidenced by: Based on LPA’s records review and interviews with staff (S1, S2 & S3), the licensee noticed a significant change in R1’s mental condition, updated their care plan as of 3/1/26 but did not notify R1’s physician for further evaluation, which poses an immediate risk to the health & safety of the residents.the state’s words, verbatim · CDSS document, Aug 11, 2026

Plan of correction: Licensee agrees to submit a written plan describing how the facility will ensure residents’ needs are met and the proper supervision is provided. Plan should address the re-appraisal process for changes in condition including inappropriate interactions with residents and staff. Written plan will be submitted to CCL by POC due date of 8/12/26. Licensee refused to sign the LIC809 and LIC809D forms acknowledging the findings. LPA printed forms and left them with the Licensee.

From the deficiency page — Deficiency type: Type B · Section cited: CCR87465(h)(5) · Plan of correction due date: Aug 18, 2026

87465 – Incidental Medical and Dental Care: (h) The following requirements shall apply to medications which are centrally stored: (5) Each resident's medication shall be stored in its originally received container. No medications shall be transferred between containers. Based on interviews conducted with the licensee and staff (S1, S2 & S3), licensee is the designated person that pre pours medications to be given to the residents in care, which poses a potential risk to the health & safety of the residents.the state’s words, verbatim · CDSS document, Aug 11, 2026

Plan of correction: Licensee agrees to stop pre-pouring medication greater than a 24 hr period. Licensee will train staff in medication management. Licensee will submit proof of training to CCL by 8/18/26. Licensee refused to sign the LIC809 and LIC809D forms acknowledging the findings. LPA printed forms and left them with the Licensee.

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Cuadra conducted an unannounced Annual Required Inspection and met with Licensee Nicholas Ray. There are three residents in care. Required postings were observed. LPA/Licensee toured the facility and observed the following: Facility passageways were free of obstruction and comfortable temperature. Smoke detectors and carbon monoxide were tested and operational. Fire extinguishers were charged and serviced November 2025. Working auditory alarms are placed on all exits. Disinfectants and cleaning solutions were stored inaccessible to residents. Hygiene and linen supplies were available. The facility has supplies of non-perishable foods for a minimum of one week and perishable foods for a minimum of two days. Last disaster drill have been conducted within the last quarter (3/1/26). Hot water temperature measured at 109 and 118.6 degrees F which is within the range allowed per regulation. LPA initiated file review at 9:30 am. LPA reviewed three residents files and three staff files. All residents have medical assessment and needs service plans are updated. All three staff have current First Aid/CPR certificates and 20 hours of additional required training. Administrator Certificate for Nicholas Ray, 7008284740, expired on 6/4/2025, LPA conducted a search into the Department's Administrator Certification Unit and was able to find Licensee's name is in the pending list as of 9/6/2025 waiting for processing. Medications and medication records were reviewed. Licensee provided updates of the following: Personnel Report (LIC500) & copy of liability Certificate. No deficiencies found during today's visit. Exit interview conducted with Licensee and copy of this report was given.the state’s words, verbatim · CDSS document, Jul 21, 2026

Allegation investigated: -Resident developed multiple pressure injuries in care requiring hospitalization, due to staff neglect.

Licensing Program Analyst (LPA) Cuadra arrived unannounced to conduct a complaint investigation and delivered findings regarding the allegation listed above and met with Nicholas Ray, Licensee. The department received a complaint allegation of resident developed multiple pressure injuries in care requiring hospitalization, due to staff neglect. The reporting party reported that facility Licensee left a resident (R1) without repositioning for extended periods of time resulting in R1 developing several pressure sores and requiring hospitalization. R1 is non-verbal, bedridden with a diagnosis of dementia. Based on records review obtained by the department revealed that on 5/02/2026, R1 was admitted to the emergency room at Providence Santa Rosa Memorial Hospital for a wound check. A wound care consult was conducted where a deep tissue injury was diagnosed on the sacrum. Also, it was observed that a small open area on the upper thoracic spine appeared to be a stage 3 pressure injury. However, the stage 3 pressure injury was never confirmed. R1 was discharged back to the care facility same day with a final diagnosis of pressure injury of the skin of the right upper back, unspecified injury stage. Continued on LIC9099C... Substantiated Continued from LIC9099... On 5/03/2026, R1 was readmitted and evaluated for the same injury the day before and diagnosed with a principal diagnosis of advanced dementia and a secondary diagnosis of pressure ulcer of the sacrum, hypertension, chronic atrial fibrillation, and hypercholesterolemia, and discharged home with hospice on 5/05/2026. On 5/5/26, LPA conducted 10-day visit to the facility to initiate complaint investigation. Based on LPA’s interviews conducted with staff (S1, S2, S3 & S4), confirmed that staff were in constant communication with Licensee regarding R1’s skin condition describing it as redness observed in the area. Interviews conducted with Licensee, it was disclosed that staff have been repositioning R1 but denied that staff communicate with them about resident's pressure injuries and despite that licensee was working nights during the week as confirmed in the facility schedule. According to licensee, the assistance with incontinence care that licensee provided to R1 was limited to open R1’s depends, but not all the way off, check that R1 was dry, then close depends. On 5/15/26 LPA requested hospice intake documentation to determine staging of pressure injuries at intake, but licensee informed LPA that R1 passed away on 5/5/26 after arriving back from the hospital. LPA reviewed incident logs for this facility and was unable to find any notification from the licensee. LPA will address reporting requirements in case management. Based on records review and interviews conducted by LPA with pertinent parties, it was revealed that R1 was not sent out timely to receive medical attention. Licensee agrees to obtain and submit death certificate to the department. The preponderance of evidence standard has been met; therefore, the above allegation is found to be SUBSTANTIATED. California Code of Regulations, (Title 22, Division 6, Chapter 8), is cited on the attached LIC 9099D. Appeal Rights Given. Failure to observe change of condition which resulted in pain per hospital notes resulted in violation causing injury to person in care $500 immediate civil penalty issued. The licensee was informed that additional civil penalties are under review by the Department per Health and Safety Code 1569.49 (f). Exit interview conducted with Licensee and copy of this report was given.the state’s words, verbatim · CDSS document, May 22, 2026 · control 21-AS-20260505100622

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87466 · Plan of correction due date: May 23, 2026

87466 Observation of the Resident The licensee shall ensure that residents are regularly observed for changes in physical, mental, emotional and social functioning and that appropriate assistance is provided when such observation reveals unmet needs. This requirement has not been met as evidence by: Based on LPA's interviews conducted with facility staff and records reviews of R1’s medical records, the facility staff failed to send R1 out timely to receive medical attention, which poses an immediate risk to the health and safety of the residents in care.the state’s words, verbatim · CDSS document, May 22, 2026

Plan of correction: The Licensee agrees to develop a procedure indicating how the facility will ensure that facility staff will regularly observe residents for changes in physical, mental, emotional & social functioning & will seek timely medical attention by POC due date 5/23/26. *** Failure to observe change of condition which resulted in pain per hospital notes resulted in violation causing injury to person in care $500 immediate civil penalty issued.

Type of visit: Case Management - Legal/Non-compliance

Licensing Program Analyst (LPA) Cuadra conducted an unannounced case management Legal/ Non-compliance inspection to this facility and deficiencies found during complaint # 21-AS-20260505100622 investigation, LPA met with Licensee Nicholas Ray. LPA was following up on items that were concerning and ensure compliance with Non-Compliance Conference dated 03/04/2026: 87405 (a) Administrator - Qualifications and Duties – Licensee failed to provide required information and documentation to carry out the solvency audit for the facility. On 4/27/26, the department’s financial unit sent an engagement letter regarding solvency audit process initiated after lack of commitment from the Licensee to provide requested financial documents pertinent to the facility. During today’s visit, LPA learned that Licensee has not submitted the requested forms and supporting documentation, but its planning to submit it timely. 87213 Finances - The licensee failed to have a financial plan that conforms to the requirements of Section 87155...shall maintain adequate financial records; submit such financial reports as may be required upon the written request of the licensing agency. The department has requested forms (LIC 401, 401A, 403 & 403A) & supporting documentation needed to conduct solvency audit to ensure facility is not in financial distress. During complaint # 21-AS-20260505100622 investigation, LPA learned after requesting resident’s (R1) hospice intake documentation to determine staging of R1's pressure injuries on 5/15/2026 when Licensee told LPA that R1 passed away on 5/5/26. Licensee could not provide an answer why they did not report to the department that R1 passed away on 5/5/26. Upon arrival, LPA smelled strong urine odor at the facility. Per Licensee, its in the process to clean the carpet to resolve the odor present at the facility. Deficiencies are cited from the California Code of Regulations (CCR), and/or the Health and Safety Code. Failure to correct the cited deficiency, on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.the state’s words, verbatim · CDSS document, May 22, 2026

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87211(a)(1)(D) · Plan of correction due date: Jun 5, 2026

87211 Reporting Requirements (1) A written report shall be submitted to the licensing agency and to the person responsible for the resident within 7 days of the occurrence of any of the events specified in (A) through (D) below…This requirement has not been met as evidence by: Based on LPA’s/Licensee records review and interviews, the licensee failed to notify the department within 7 days of occurrence that R1 passed away on 5/5/26, which poses a potential risk to the health & safety of residents in care.the state’s words, verbatim · CDSS document, May 22, 2026

Plan of correction: Licensee to ensure incidents are reported per regulation. Licensee agrees to review regulation 87211 and conduct training for all staff on reporting requirements. Evidence of completed training to be submitted to CCL by POC date of 06/05/2026..

From the deficiency page — Deficiency type: Type B · Section cited: CCR87303(a)(1) · Plan of correction due date: Jun 5, 2026

87303 Maintenance and Operation (a) The facility shall be clean, safe, sanitary & in good repair at all times... (1) Floor surfaces in bath, laundry & kitchen areas shall be maintained in a clean, sanitary, and odorless condition. This requirement has not been met as evidence by: Based on LPAs/Licensee and interviews with Licensee, the licensee failed to ensure that the facility was sanitary & odor free. LPA observed a strong urine smell in the facility, which poses a potential risk to the health & safety of the residents.the state’s words, verbatim · CDSS document, May 22, 2026

Plan of correction: Licensee to ensure that the facility is sanitary, clean & odorless at all times; Licensee to determine the way to control the odor & submit an LIC 9098 self certification that the facility is free of odor by POC due date 06/05/2026.

Type of visit: Office

A Non-Compliance meeting was conducted today in the Santa Rosa Regional Office. Present in the meeting were Regional Manager Carla Nuti-Martinez, Licensing Program Manager Bethany Moellers, Licensing Program Analyst Marisol Cuadra and Licensee of the facility, Nicholas Ray. The purpose of the Non-Compliance Plan conference is to address concerns found during solvency audit conducted by the Department to ensure that the facility is not in financial distress. After unsuccessful attempts made by the Department to obtain requested documentation, the Licensee failed to provide required information and documentation to carry out the solvency audit. Due to the licensee’s failure to comply with records requested is resulting in the facility being put on a two year non-compliance plan. Refer to licensing report, LIC 9111, for further information. Licensee advised that failure to comply with solvency audit may result in administrative action. A subsequent referral for audit will be requested. There was a discussion about Technical Support Program (TSP) referral and Licensee agreed to be referred to the TSP program and referral will be submitted. Deficiencies are cited from the California Code of Regulations (CCR), and/or the Health and Safety Code. Failure to correct the cited deficiency, on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment. Exit interview conducted with Licensee and copy of report was given.the state’s words, verbatim · CDSS document, Mar 4, 2026

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87405(a) · Plan of correction due date: Mar 9, 2026

87405 Administrator - Qualifications and Duties. (a) All facilities shall have a qualified and currently certified administrator. This requirement is not met as evidenced by: Based on LPA's/Licensee observation, interviews and record review, the licensee did not comply with the section cited above in that Licensee keeps failing to follow up with the Department Audit Unit, which poses a potential risk to the health, safety, or personal rights to persons in care.the state’s words, verbatim · CDSS document, Mar 4, 2026

Plan of correction: The Licensee agrees to submit written statement agreeing to comply with Department's solvency audit to clear the citation by POC due date of 3/9/2026.

From the deficiency page — Deficiency type: Type B · Section cited: CCR87213 · Plan of correction due date: Mar 9, 2026

87213 Finances - The licensee shall have a financial plan that conforms to the requirements of Section 87155, Application for License, and that assures sufficient resources to meet operating costs for care of residents; shall maintain adequate financial records; and shall submit such financial reports as may be required upon the written request of the licensing agency…This requirement has not been met as evidence by: Based on a financial audit conducted by the department, the facility did not have an adequate financial plan to meet regulation, which poses a potential risk to the health and safety of residents in care.the state’s words, verbatim · CDSS document, Mar 4, 2026

Plan of correction: The Licensee agrees to submit written statement agreeing to comply with Department's solvency audit to clear the citation by POC due date of 3/9/2026.

Type of visit: POC

Licensing Program Analyst (LPA) Cuadra arrived unannounced , to conduct a Plan of Correction (POC) visit and met with Licensee, Nicholas Ray. On 08/28/2025, LPA issued a citation for a violation of California Code of Regulation section 1569.652 with a plan of correction (POC), which are outstanding as of today. The POC called for the Licensee to provide proof of refund to resident's (R1) responsible party regarding the regulation: 1569.652 Termination of admission agreement requirement. Proof of refund was requested to be submitted to CCL to clear the citation by POC due date of 09/15/25. During today's visit, Licensee provided proof of correction for citation 1569.652 - Deficiency cleared from Substantiated allegation visit 08/28/2025. Copies of documents obtained indicated that Licensee have submitted as of November 17, 2025, an online payment in the amount of $999 with confirmation# ibq4tbhzm and another transfer made online in the amount of $1 with confirmation #d8i98a9nf to resident's responsible party and agreed to pay the full refund amount of $2000 by not later than December 1, 2025. The deficiency is cleared by POC visit. LPA have a conversation with the Licensee and provided regulation: 87507 Admission Agreements for their review. No deficiencies cited during today's visit. Exit interview with Licensee and copy of this report was given.the state’s words, verbatim · CDSS document, Nov 21, 2025

Type of visit: Office

An informal meeting was conducted today in the Santa Rosa Regional Office. Present in the meeting were Licensing Program Manager Bethany Moellers, Licensing Program Analyst Marisol Cuadra and Licensee of the facility, Nicholas Ray. The purpose of the informal conference is to address concerns found during complaint #21-AS -20250826155234 substantiated findings regarding financial issue, which it was discussed with Licensee. The department has offered to complete a financial audit on the licensee; The purpose of the audit is to ensure there are sufficient resources necessary to meet operating costs for the proper care of its residents and sufficient funds to meet the licensee's financial obligations. The audit will provide a solvency audit report to determine if the Licensee has an adequate financial plan to satisfy the California Code of Regulations, Title 22, Division 6, Chapter 8, Section 87213. -Licensee agrees to submit two months of bank statements for Live Oak Rest Home # 496803811 by not later than 10/3/25. Licensee agrees to submit proof of liability insurance for the home as discussed by not later than 10/3/25. No deficiencies found during today’s office meeting. Exit interview conducted with Licensee & copy of report was given.the state’s words, verbatim · CDSS document, Sep 29, 2025

Allegation investigated: -Staff did not issue a refund to resident's authorized representative.

Licensing Program Analyst (LPA) Cuadra conducted a complaint investigation regarding the above allegation. Licensee was out of town unable to come to the facility but was available via phone and gave authorization to staff to sign the report. LPA reviewed resident and facility records and interviewed Licensee. Per Reporting party, Resident (R1) passed away on April 9, 2025, and they removed R1’s belongings as of April 14, 2025. According to the admission agreement, the licensee agrees to refund any fees within 15 days paid in advance covering the time after the residents’ items have been removed. Based on interviews conducted by LPA with the Licensee it was confirmed that R1's personal belongings were removed from the room, and they agreed with R1’s responsible party to round down the refund to $3000, but according to the Licensee there have been some pinches. However, Licensee stated that the facility will be issuing the refund to R1’s responsible party by not later than September 15, 2025, and it was communicated to R1’s responsible party on 8/27/25 via phone. A balance is still due to be paid to responsible party/authorized representative for the remaining days. The preponderance of evidence standard has been met; therefore, the above allegations are found to be SUBSTANTIATED. California Code of Regulations, (Title 22, Division 6, Chapter 8), is being cited on the attached LIC 9099D. Appeal Rights given. Substantiatedthe state’s words, verbatim · CDSS document, Aug 28, 2025 · control 21-AS-20250826155234

From the deficiency page — Deficiency type: Type B · Section cited: HSC 1569.652 · Plan of correction due date: Sep 15, 2025

1569.652 Termination of admission agreement upon death of resident; removal of resident’s property; refund of fees paid; notice of contract termination and refunds. This requirement was not met as evidenced by*** Based on LPA's record review and interview with Licensee, the facility failed to ensure R1's responsible party received a refund in the amount of $3000 based on facilitys own admission agreement in compliance with Title 22 which poses a potential health and safty risk to residents in care.the state’s words, verbatim · CDSS document, Aug 28, 2025

Plan of correction: Licensee to refund $3000 fees paid to resident's responsible party. Proof of refund to be submitted to CCL by POC due date.

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Cuadra conducted an unannounced Annual Required Inspection and met with Licensee Nicholas Ray. Licensee informed of outstanding fees of $247.50. LPA/Licensee initiated a tour of the facility at 9:00 am. Facility passageways were free of obstruction and comfortable temperature. Smoke detectors and carbon monoxide was tested and operational. Two fire extinguishers were charged and serviced November 2024. Working auditory alarms are placed on all exits. Disinfectants and cleaning solutions were stored inaccessible to residents. Hygiene and bedding supplies were available. The facility has supplies of non-perishable foods for a minimum of one week and perishable foods for a minimum of two days maintained on the premises. Last disaster drill have been conducted within the last quarter (6/1/25). Required postings were observed. During tour of the facility LPA/Licensee observed a intake vent that needs cover located in the hallway leading to bedroom #4 (technical violation issued). At approximate 9:15 am LPA/Licensee observed hot water temperature measured at 129.9 and 134.8 degrees F which is not within the range allowed per regulation. Licensee adjusted water heater immediately. At approximately 9:30am LPA/Licensee had a conversation regarding no activities were conducted during LPA's visit. According to Licensee, there are some residents that go out for a quick walk, but there are others that no have any interest on doing them (technical violation issued). Continues on LIC809C... Continued from LIC809... During tour of the facility LPA/Licensee observed a camera located in the facility common area. Previously, LPA/Licensee discussed that if there were cameras located in common areas, all resident's admission agreements were needed to be updated reflecting the use of cameras without audio in common areas. However, during file review it was revealed that admission agreements were not updated as instructed by LPA during last annual conducted on 7/30/24 to indicate the use of surveillance cameras in the common areas. Licensee agreed to elaborate an addendum to admission agreements. LPA initiated file review at 10:00 am. LPA reviewed five residents files and three staff files. One out of five residents (R1) needs medical assessment to be updated. Two out of five resident's (R1 & R2) needs service plans needs to be updated. LPA/Licensee discussed Dementia regulation changes and provided resources including LIC602A form for their review. All four out of four staff do have current First Aid/CPR certificates and 20 hours of additional required training. Administrator Certificate for Nicholas Ray, 6027071740, expires on 6/24/2025. Medications and medication records were reviewed. Licensee to submit updates of the following documents by 6/27/2025: Designation of Administrative Responsibility (LIC308), Personnel Report (LIC500) and copy of liability Certificate. Deficiencies cited from the California Code of Regulations, Title 22, Division 6 of California Regulation. Appeal rights given. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties. Exit interview conducted with Licensee and copy of this report was given.the state’s words, verbatim · CDSS document, Jun 10, 2025

The state marks this report as 8 pages; the online copy we transcribed has 6. You can request the full file from the county licensing office.

Allegation investigated: -Personal Rights

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 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.the state’s words, verbatim · CDSS document, Jul 30, 2024 · control 21-AS-20240508100012

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Cuadra conducted an unannounced Annual Required Inspection and met with Licensee Nicholas Ray. Annual fees are current. Contact information was reviewed. LPA/Licensee initiated a tour of the facility at 9:00 am. Facility passageways were free of obstruction. Hot water temperature measured at 124.7 and 123.4 degrees F which is not within the range allowed per regulation (technical violation issued). Licensee adjusted water heater immediately. Smoke detectors and carbon monoxide was tested and operational. Two fire extinguishers were charged and serviced December 2023. Working auditory alarms are placed on all exits. Disinfectants and cleaning solutions were stored inaccessible to residents. Hygiene and bedding supplies were available. Non-perishable and perishable food supply met the minimum requirements. Required postings were observed. Medications and medication records were reviewed. -No activities were conducted during LPA's visit. LPA/Licensee discussed the importance of having activities on a regular basis (technical violation was issued). -Last disaster drill have not been conducted within the last quarter (technical violation was issued). -Garbage cans located in the bathrooms did not have cover to prevent the transmission of communicable disease or odors (technical violation was issued). LPA initiated file review at 10:00 am. LPA reviewed five residents files and three staff files. Residents medical assessments and needs service plans are current. One out of three staff do not have current First Aid/CPR certificates (technical violation issued). Two out of three staff (S1 & S2) needs 20 hours of additional required training. Administrator Certificate for Nicholas Ray, 6027071740, expires on 6/24/2025. Continue on LIC809C... Continued from LIC809... During tour of the facility LPA/Licensee observed a camera located on top of a dresser in shared resident's (R1 & R2) bedroom. LPA found that the camera was purchased by the Licensee with the purpose of motion sensor and does not recording nor auditory device to alert staff during overnight hours. LPA/Licensee discussed the need for an exception in order to continue using the camera in R1's & R2's bedroom as it is a private space and potential violation of resident rights. Licensee removed camera immediately and agreed to review with both resident's family and submit an exception letter request to CCLD along with appropriate documentation if they are in agreement or replace it with a motion detector device. Otherwise, the licensee agreed to don't install them back to the shared bedroom. The Department to review and return at a later date. Also, there are cameras located in common areas and resident's admission agreement were not updated reflecting the use of cameras without audio in common areas. Licensee to submit updates of the following documents by 8/16/2024: Designation of Administrative Responsibility (LIC308), Personnel Report (LIC500) and copy of liability Certificate. Deficiencies cited from the California Code of Regulations, Title 22, Division 6 of California Regulation. Appeal rights given. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties. Exit interview conducted with Licensee and copy of this report was given.the state’s words, verbatim · CDSS document, Jul 30, 2024

The state marks this report as 8 pages; the online copy we transcribed has 3. You can request the full file from the county licensing office.