Routine inspection·September 30, 2025

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.