State inspectors found that a six-bed elder care home on Live Oak Avenue in Sebastopol didn’t get a bedridden resident with pressure injuries to medical care in time, according to a May 22 state report. The inspector learned the resident had died only after asking the home for hospice paperwork.
Since May, the California Department of Social Services’ Community Care Licensing Division has issued six Type A citations to Live Oak Rest Home, 604 Live Oak Ave. That’s the category for violations that, if not corrected, “have a direct and immediate risk to the health, safety, or personal rights of persons in care.” Nicholas Ray is the licensee and administrator. The home remained licensed for six residents as of Oct. 11, according to the state’s online facility search, which posts the reports.
A resident’s pressure injuries
Hospital records the state reviewed show the resident, described in the report as “non-verbal, bedridden with a diagnosis of dementia,” went to a Santa Rosa emergency room May 2 and was sent home with hospice care May 5. A complaint received May 5 alleged the resident was left without repositioning for long stretches. On May 22, the state substantiated it: “Resident developed multiple pressure injuries in care requiring hospitalization, due to staff neglect.”
Staff told the analyst they’d been “in constant communication” with Ray about redness on the resident’s skin. Ray said staff had been repositioning the resident and denied that staff had told him about the injuries, the report says.
The state concluded the resident “was not sent out timely to receive medical attention.” It issued a “$500 immediate civil penalty” for a violation “causing injury to person in care” and told Ray that “additional civil penalties are under review.”
On May 15, when the analyst asked for hospice records, Ray said the resident had died May 5 after coming back from the hospital. A companion report says Ray “could not provide an answer why they did not report” the death within seven days, as state rules require, and cites the home for it. The reports do not state a cause of death.
Fires and a call for more staff
On Aug. 11, the state substantiated three allegations from a June complaint: that the home didn’t prevent a resident from starting fires or make sure the resident was bathed, and kept a resident whose presence posed a risk to others.
The complainant told the state the resident “has started multiple fires in the facility,” which the complainant called dangerous because “most of the residents are non-ambulatory.” Staff and Ray told the analyst the resident brought in lighters and matches and tried to set a shared bathroom on fire in April, the report says. Photos showed fire damage. Records confirmed that four of five residents were non-ambulatory.
The report says the same resident tried to pull a roommate out of bed in March and attacked a staff member with a knife in May. The state told Ray on March 30 to add staff. He hadn’t, the state found.
The state issued three Type A citations from that complaint, for not providing the supervision the resident needed, not meeting the resident’s hygiene needs and failing “to hire additional staff.” Six other allegations, including that Ray mismanaged medication, yelled at residents and provided no care at night, weren’t substantiated, meaning the state didn’t find enough evidence to show whether they happened.
A separate report the same day cited Ray for noting a significant change in the resident’s mental condition in a March 1 care plan without telling the resident’s physician, and for pre-pouring residents’ medications. He agreed “to stop pre-pouring medication greater than a 24 hr period.” The report says Ray “refused to sign” the forms acknowledging the findings.
Money and the solvency audit
On Aug. 28, 2025, the state substantiated a complaint that the home had not refunded $3,000 in prepaid fees to the representative of a resident who died that April. Ray told the analyst there had been “some pinches.” The state cleared that citation in November after Ray showed proof of payments. In between, the department offered a financial audit “to ensure there are sufficient resources necessary to meet operating costs for the proper care of its residents.”
On March 4, after what the report calls “unsuccessful attempts” to get records, it found “the Licensee failed to provide required information and documentation to carry out the solvency audit.” It put the home “on a two year non-compliance plan” and told Ray that not complying “may result in administrative action.”
In May the forms still hadn’t been sent, though Ray was “planning to submit it timely,” the analyst wrote. At the Sept. 24 visit, Ray said he’d submitted everything the department’s financial unit requested, according to the report.
No certified administrator
State rules require “a qualified and currently certified administrator.” Ray’s certificate expired June 4, 2025. A July 21 annual inspection, which found no deficiencies, noted his renewal had been on the state’s pending list since Sept. 6, 2025.
The next day, the analyst told Ray to follow up with the state’s certification unit. On Sept. 24, the analyst found he hadn’t. Ray called the unit during that visit and left a voicemail, the report says. The department’s portal showed his application was incomplete for “insufficient (CEU/fee).”
The state issued a Type A citation and a $250 penalty “due to repeated citation within 12 months.” Ray agreed to send the state proof that he had written to the unit for guidance on renewing.