Oak Tree Lodge

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Alviso, arrived unannounced to conduct a Required -1 Year inspection, on 8/15/23 at approximately 11:05am, and met with Sandra Ambrecht, lead caregiver. Licensee/Administrator Pamela Johnson was notified of LPA's arrival. 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 six(6) residents in care; One(1) resident is on hospice services. The LPA reviewed six(6) 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 107.9F. All exits were clear and unobstructed. The bathrooms all have grab bars as needed. Showers have mats/non-slip flooring for resident use. Facility has sufficient furnishings for resident use. Facility has sufficient lighting throughout the facility, in resident rooms, bathrooms, and common areas. LPA observed a sufficient supply of food, perishable and nonperishable. Facility had all toxins/disinfectants locked up and inaccessible to residents in care. All medications were locked up and inaccessible to residents in care. Continued on LIC809C.... All postings were up and visible to all as required. Facility had a sufficient supply of hygiene products, paper products, and personal protective equipment(PPE) for use as needed. Fire extinguishers, two(2), were serviced and tagged as required -expires 7/3/24. Per facility fire drill reviews, last drills conducted were Fire & Earthquake, held on 4/1/23 and 6/1/23. All smoke alarms, eight(8), were working properly during the inspection. The carbon monoxide detector was part of the smoke alarm check, one of the hardwired alarms is also a carbon monoxide detector, it was working properly during the inspection. LPA is requesting the following documents be updated and submitted by 9/15/23: LIC308 - Designation of Administrator Responsibility LIC610E-Emergency Disaster Plan (update as needed & submit) LIC400 Handling of Client Cash Resources Copy of Surety Bond if handling cash. Copy of Current Liability Insurance Copy of Updated Infection Control Plan Copy of Administrator Certificate The LPA observed resident room four(4) to have a strong smell of urine odor. The room is rugged, and the resident is incontinent. LPA discussed with the staff regulations on incontinent care, and ensuring the facility is free of urine odors.. The room is rugged, and the resident is incontinent. LPA discussed with the staff regulations on incontinent care, and ensuring the facility is free of urine odors. This deficiency will be cited, 87625(b)(3) Managed Incontinence, Ensuring that incontinent residents are kept clean and dry and that the facility remains free of odors from incontinence, see LIC809D. The following deficiency was cited from the California Code of Regulations, Title 22, Division 6, Chapter 8 of California Regulation. Failure to correct the deficiency(s) and/or repeat deficiencies within a 12 month period may result in civil penalties. Exit interview conducted with Lead Caregiver Appeal Rights provided to the Administrator.the state’s words, verbatim · CDSS document, Aug 15, 2023

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Alviso, arrived unannounced to conduct an Required-1 Year inspection and met with Sandra Ambrecht, lead caregiver/back-up to the Administrator. This inspection is focused on the Infection Control procedures and practices of the facility. Facility has an approved dementia plan of operation. There is an approved hospice waiver for one(1) resident. The new updated Infection Control Plan was recently submitted as required by the Department. Fire clearance is approved for six (6) non-ambulatory. There were six (6) residents in care at the facility during the inspection. Residents are screened daily, and observed for any changes, all information is logged. Facility was found to be at a comfortable temperature for the residents in care. LPA observed all exits free from obstruction. Toxins are stored in locked cabinets. There was a sufficient supply of hygiene products, cleaners, and paper products for use as needed. Medications were stored locked making them inaccessible to residents in care. All exit alarms were on exit doors and working properly. All bathrooms had grab bars, and non-slip mat/flooring for bathing as needed. All postings were up and visible to all as required. Facility has a sufficient supply of personal protective equipment(PPE) for use by staff and others, residents and/or visitors as needed or wanted. Staff Sam was observed wearing a mask, as required, upon LPA's entry into the facility. LPA observed the following during the inspection: Staff didn't screen the LPA upon entry and/or at any time ask to screen the LPA. The LPA discussed the screening requirements with staff Sam. This deficiency will be cited, Administrator Qualifications and Duties 87405(d)(2)-see LIC809D. Continued on page LIC809C.. LPA observed a large pair of scissors in a resident's room (R1), and observed three pairs of small scissors and a metal sharp pointed mail opener in another resident's room (R2); These items pose a danger and risk for residents in care, this deficiency will be cited, Care Of Persons With Dementia 87705(f)(1). LPA observed a residents room to smell strongly of urine: LPA observed that the residents bathroom also smelled strongly of urine. The LPA observed that the rug in front of the residents bed showed that there were many stains; Staff stated to the LPA they didn't notice the stains. LPA asked if the rug in the residents room is cleaned on a regular basis, and the incontinent resident's bed wiped down as needed as staff stated to the LPA that the resident was changed and is clean and dry. The staff stated to the LPA the rug was cleaned a about a month ago, and the resident's bedding is washed as needed. LPA stated that part of caring for incontinent residents is to also ensure that the facility remains free of urine odors. Deficiency cited, 87625(b)(3) Managed Incontinence. LPA observed two(2) facility fans that had very dirty fan blades with lots of dust accumalated-both fans were running. LPA obtained pictures. The staff turned both the fans off and acknowledged to the LPA that the fans were dirty and needed to be cleaned. This deficiency will be cited, Maintenance and Operation 87303(a). All deficiencies cited are found on LIC809D pages. Licensee to submit by 8/31/22 the following updated forms: LIC308 - Designation of Administrator Responsibility LIC500 - Updated Personnel Report LIC610 - Updated Emergency Disaster Plan, Copy of Current Lease Agreement(if home leased to the Licensee) Copy of Current Liability Insurance Copy of current Administrator Certificate Copy of updated Disaster/Emergency Evacuation plan. Deficiencies cited from the California Code of Regulations, Title 22, Division 6 and/or Health & Safety Code Deficiencies not corrected within specified time frame and/or repeat violations within 12 months, may result in civil penalties being assessed. Exit interview conducted with staff Sam Ambrecht. Appeal rights provided for the Administrator.the state’s words, verbatim · CDSS document, Aug 17, 2022

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Alviso, conducted a Case Management Incident Inspection on 12/6/21 at approximately 11:30, and met with Sam Ambrecht lead caregiver/Administrator Assistant. LPA was screened for covid symptoms, and temperature was taken, before LPA was allowed to stay in the facility. LPA advised facility staff to use a covid symptoms questionnaire of some kind such as the CDC's covid symptom questions to be asked of each person, individual, staff, and residents, entering the facility. Sam Ambrecht, caregiver printed out copies of the form from the CDC website and immediately put them out on the screening table to be used. LPA reviewed resident incident, and discussed the incident with staff. LPA met with the resident in care. LPA has received documentation and information from the administration staff regarding the incident and all follow-up. Administration staff addressed the incident, notified all required party(s), and completed required reporting. Administration staff will keep Licensing updated as needed and required. Administration staff will ensure the resident's current needs are met; Administration staff will ensure that the facility can meet all resident's care needs. No deficiencies cited today.the state’s words, verbatim · CDSS document, Dec 6, 2021

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Dina Alviso, arrived unannounced to conduct an Annual Required inspection and met with Assistant Administrator Sandra Ambrecht. The inspection is focused on the Infection Control procedures and practices of this facility. Facility has an approved dementia plan of operation. There is an approved hospice waiver for one(1) resident. Mitigation plan was approved by the Department on 7/12/21. Fire clearance is approved for six (6) non-ambulatory; Fire Department was out on 7/12/21 and did the yearly inspection, facility passed per the fire department report. Fire extinguishers were tagged and serviced as required-8/9/21.There were 6 residents in care at the facility during this inspection. All visitors, essential visitors, and staff are screened upon entry; Temperatures are taken, and screening questions are to be answered before being allowed to remain in the facility, all information is logged. Residents are screened twice daily, and observed for any changes, all information is logged. Facility was found to be clean, orderly, and at a comfortable temperature with all exits free from obstruction. Toxins are stored in locked cabinets. There was a sufficient supply of hygiene products, cleaners, and paper products for use as needed. Medications were stored locked making them inaccessible to residents and staff that do not handle medications. All exit alarms were on exit doors and working properly. All bathrooms had grab bars, and non-slip mat/flooring for bathing as needed. All postings were up and visible to all as required. Facility has a sufficient supply of personal protective equipment(PPE). Administrator stated that staff wear masks in the facility, and also when providing care services to the residents in and out of the facility. Administrator had a mask on during the LPA's inspection. No deficiencies found in the areas inspected. Exit interview conducted with the Administrator.the state’s words, verbatim · CDSS document, Aug 27, 2021