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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496803676
Report Date: 07/11/2024
Date Signed: 07/11/2024 12:29:13 PM


Document Has Been Signed on 07/11/2024 12:29 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SANTA ROSA RO, 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: DATE:
07/11/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:51 AM
MET WITH:Ruby Moreno, AdministratorTIME COMPLETED:
12:43 PM
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Licensing Program Analyst (LPA) Christi Coppo arrived unannounced to conduct a required Annual inspection and was greeted by caregiver. Administrator Ruby Moreno arrived later. Facility contact information was reviewed.

At approximately 9:00am LPA toured the building and grounds. The facility was found to be clean and at a comfortable temperature. LPA observed at least a 2 day supply of perishable and 7 day supply of non-perishable food. Food was found to be stored in a safe manner with open items covered. Kitchen drawer with sharp knives locked.

All bedrooms were equipped with lighting, night stand, and chest of drawers. All bedrooms were clean and in good repair. Extra hygiene products and linens were available. Resident bathrooms had required bath mat and grab bar. Water temperature in sink accessible to residents in care measured at 110.2, 119.3, and 118.9 degrees F which is within the allowable range of 105 to 120 degrees F.

Fire extinguishers were last inspected 8/28/2023. Smoke/Carbon Monoxide detectors located throughout the facility were operational. Facility’s last quarterly disaster drill was conducted 6/21/2024.

At approximately 10:30am LPA conducted a review of 6 resident records. All required documentation present. 1/2 rails on file.

At approximately 11:15am LPA conducted review of 5 staff records. All required documentation present.



Continued on 809C...
SUPERVISOR'S NAME: Victoria BertozziTELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Christi CoppoTELEPHONE: (707) 588-5054
LICENSING EVALUATOR SIGNATURE:
DATE: 07/11/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/11/2024
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
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME: SONOMA OAK TREE PLACE
FACILITY NUMBER: 496803676
VISIT DATE: 07/11/2024
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Continued from 809...

At approximately 12:00pm LPA and Admin conducted a spot check of medication and medication records. Medication is centrally stored in a locked cabinet. No deficiencies

Ruby Moreno Administrator Certificate 703601740 expires 2/1/2025. All fees are current as of this time.



LPA and Administrator discussed facility's Infection Control Plan and Emergency Disaster plan. No new updates.

Updated copies of the following documents were requested for facility file and are to be submitted to CCL within 30 days of this visit:

LIC500- Personnel Report
LIC308- Designation of Responsibility
Liability Insurance
Current Lease or Deed

No deficiencies cited during this inspection. Exit interview conducted with Administrator and a copy of this report was given.

SUPERVISOR'S NAME: Victoria BertozziTELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Christi CoppoTELEPHONE: (707) 588-5054
LICENSING EVALUATOR SIGNATURE:

DATE: 07/11/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/11/2024
LIC809 (FAS) - (06/04)
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