Oak Tree Lodge

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Alviso, arrived unannounced to conduct a Required - 1 Year inspection, on 9/30/2025 at approximately 10am, and met with Sandra Ambrecht, Administrator. Facility has an approved dementia plan of operation. There is an approved hospice waiver for one(1) resident. The facility has a required infection control plan. The facility has a required emergency disaster plan. Fire clearance is approved for six (6) non-ambulatory. There are currently four (4) residents in care. The LPA reviewed four (4) resident files. All files were complete. The LPA reviewed three(3) staff files. All staff have required criminal record clearance. All staff have current First Aid and CPR as required. All staff have training as required. LPA toured the facility with the Administrator. All exits were free and clear of obstructions. Fire extinguishers were serviced and tagged as required. All rooms were clean and orderly. Food supply was sufficient in perishable and non-perishable food items. Sufficient supply of disinfectants/cleaners, paper products, personal protective equipment (PPE), linens, and furnishings. Medications were locked up and inaccessible to residents in care. Hot water measured at 116.4 Fahrenheit. All cleaners/disinfectants were locked and inaccessible to residents in care. LPA observed sufficient lighting in common areas, hallways, bathrooms, and resident rooms. There was seating outside on the facility's porch/deck which is accessible from resident rooms slider doors, and seating in the front area for residents' use. Continued on LIC809C... LPA is requesting the following documents be submitted by 10/30/2025: LIC308 - Designation of Administrator Responsibility LIC500 - Personnel Report LIC610 - Emergency Disaster Plan (9-Page)- update if needed- submit if changes Copy of Current Liability Insurance Copy of current Administrator Certificate Copy of updated Infection Control Plan- update if needed- submit if changes LIC400-Affidavit of Client Cash Resources (Complete form as required) Copy of Surety Bond if handling cash LPA observed the following deficiencies during the inspection: Per LPA facility record review, and LPA’s review in the Guardian system, it was found that staff, S4, was not associated to the facility, Oak Tree Lodge. This deficiency will be cited, 87355(c) Criminal Record Clearance- A licensee or applicant for a license may request a transfer of a criminal record clearance from one state licensed facility to another, or from Trust Line to a state licensed facility by providing the documents to the Department, see LIC809D. Due to the violation being cited, there is a civil penalty assessed in the amount $100, see LIC421BG. 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. Exit interview conducted with Administrator. Appeal rights given to Administrator Sandra Ambrecht.the state’s words, verbatim · CDSS document, Sep 30, 2025

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Alviso, arrived unannounced to conduct a Required -1 Year inspection, on 10/16/24 at approximately 9:40am, and met with Sandra Ambrecht, Administrator. Facility has an approved dementia plan of operation. There is an approved hospice waiver for one(1) resident; Currently there is one (1) resident on hospice care. The facility has a required infection control plan. The facility has a required emergency disaster plan. Fire clearance is approved for six (6) non-ambulatory. There are currently five (5) residents in care. Per file review, quarterly fire/evacuation/emergency disaster drills are being conducted as required. The LPA reviewed five (5) resident files. All files were complete. The LPA reviewed three(3) staff files. All staff have required criminal record clearance. All staff have current First Aid and CPR as required. All staff have training as required. The LPA toured the facility with caregiver Sam. Hot water was checked at 106.7 degrees Fahrenheit. All exits were clear and unobstructed. All exit doors had auditory alarms. Fire extinguishers were serviced as required, dated 7/2/24. Medications were locked up and inaccessible to residents in care. All cleaners/disinfectants were locked up and inaccessible to residents in care. There was sufficient lighting in resident rooms, hallways, bathrooms, and all common areas. LPA observed a sufficient supply of food, perishable and non-perishable. Sufficient supply observed regarding, hygiene supplies, linens, personal protective equipment (PPE), paper products, and disinfectants/cleaners. Common areas were found to be clean and orderly. Resident rooms 1, 2, 3, 4, and 6, were observed to be clean and orderly. Sufficient furnishings observed throughout the facility for resident use. Continued on LIC809C.. LPA is requesting the following documents be updated and submitted by 11/16/24: LIC308 - Designation of Administrator Responsibility LIC500 - Personnel Report LIC610E- Emergency Disaster Plan -Review and submit plan if any changes. If no changes, submit last page (write at top which plan) signed & dated of when reviewed and by who. Infection Control Plan- Review and submit plan if any changes. If no changes, submit last page (write at top which plan) signed & dated of when reviewed and by who. Copy of LIC400 Handling of Client Cash Resources (include copy of surety bond if handling cash) Copy of Current Liability Insurance Resident Roster Copy of current Administrator Certificate when received The following deficiencies were observed by the LPA during the inspection: LPA observed resident's (R1) room, #5,to have a very strong smell of urine, in resident's room and bathroom; The resident is incontinent per file review, and interview with staff S1. S1 stated that they are aware the room smells of urine, and has cleaned the room and bathroom daily, but can't get rid of the urine smell. S1 doesn't know if it's the resident's bathroom, toilet, flooring and/or room, such as the resident's rug. This deficiency will be cited, 87625(b)(3) Managed Incontinence-In addition to Section 87611, General Requirements for Allowable Health Conditions, the licensee shall be responsible for the following: Ensuring that incontinent residents are kept clean and dry and that the facility remains free of odors from incontinence, see LIC809D. LPA observed that there is a outlet with a coveplate missing in resident room #1's bathroom. There is a large dirty, grease spot above the stove range on the kitchen ceiling that needs to be cleaned really well. There is a door in the kitchen where at the top of this door looks to be sheetrock (drywall) crumbling and falling apart. LPA obtained pictures. This deficiency will be cited, 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. Exit interview conducted with Administrator. Appeal rights given to Administrator Sandra Ambrecht.the state’s words, verbatim · CDSS document, Oct 16, 2024