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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496803676
Report Date: 07/24/2023
Date Signed: 07/24/2023 11:38:06 AM


Document Has Been Signed on 07/24/2023 11:38 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405



FACILITY NAME:SONOMA OAK TREE PLACEFACILITY NUMBER:
496803676
ADMINISTRATOR:MORENO, RUBYFACILITY TYPE:
740
ADDRESS:19326 SOLANO CTTELEPHONE:
(707) 695-2426
CITY:SONOMASTATE: CAZIP CODE:
95476
CAPACITY:6CENSUS: 5DATE:
07/24/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:15 AM
MET WITH:Caregiver, Yadira Garcilazo
Assistant Administrator, Shanti Ragland 		TIME COMPLETED:
11:45 AM
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Licensing Program Analyst (LPA), Farhaan Sarangi arrived unannounced at Sonoma Oak Tree Place for the purpose of conducting a Required 1 year inspection. LPA was greeted at the door by Caregiver, Yadira Garcilazo, and was granted access into the facility. Assistant Administrator, Shanti Ragland arrived 20 minutes later.

LPA and the Assistant Administrator toured the one story facility. LPA observed the facility to be clean and at a comfortable temperature with all exits free from obstruction. 2 of 2 Fire Extinguishers were found to be last charged on September 2022 at the time of the inspection. All smoke detectors and carbon monoxide detectors were tested and found to be operational during the inspection. Auditory Devices were operational during the Required 1 year inspection. First Aid kit was inspected and found to be appropriate during the inspection. Water temperature in 3 of 3 residents bathroom measured at 114 degrees and is within acceptable range of 105 to 120 degrees F. There was sufficient perishable and non-perishable foods located in the kitchen. Knives and other hazardous items were locked and inaccessible to residents in care. There are special provisions made for individuals with special dietary needs. Food menu was presently available for viewing during the inspection. Cleaning products and other toxins are located in the locked laundry room and inaccessible to residents in care. There was a supply of Linens, cleaners, hygiene products and paper products available for residents in care during the Required 1 year inspection. All bathrooms designated for residents in the common areas at the facility were supplied with individual paper towels and hand soap. Bathrooms in resident’s rooms have a towel and soap. Bathrooms were equipped with necessary grab bars, and non-slip floors/mats were observed. A tour of all residents bedrooms were conducted, and bedrooms inspected have lighting and appropriate furnishing. LPA advised facility to contact County Public Health and Community Care Licensing immediately if symptoms or COVID-19 + or any other infectious diseases in the facility. LPA reviewed the Infection Control Plan. LPA reviewed the Emergency Disaster Plan. (Report continued on LIC 809C)
SUPERVISOR'S NAME: Hope DeBenedettiTELEPHONE: (707) 588-5029
LICENSING EVALUATOR NAME: Farhaan SarangiTELEPHONE: 707-588-5034
LICENSING EVALUATOR SIGNATURE:
DATE: 07/24/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/24/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME: SONOMA OAK TREE PLACE
FACILITY NUMBER: 496803676
VISIT DATE: 07/24/2023
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Staff files, resident files and medication files will be reviewed at a later date and time. Staff and resident interviews will be conducted at a later date and time.

No deficiencies were observed or cited during today's Required 1 year inspection. Exit interview was conducted and a copy of this report was given to the Assistant Administrator.
SUPERVISOR'S NAME: Hope DeBenedettiTELEPHONE: (707) 588-5029
LICENSING EVALUATOR NAME: Farhaan SarangiTELEPHONE: 707-588-5034
LICENSING EVALUATOR SIGNATURE:

DATE: 07/24/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/24/2023
LIC809 (FAS) - (06/04)
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