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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496803864
Report Date: 11/05/2021
Date Signed: 11/05/2021 11:03:30 AM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928
FACILITY NAME:SONOMA OAK TREE HOMEFACILITY NUMBER:
496803864
ADMINISTRATOR:ROWLANDS, CHRISTINAFACILITY TYPE:
740
ADDRESS:425 ARBOR AVETELEPHONE:
(707) 287-6214
CITY:SONOMASTATE: CAZIP CODE:
95476
CAPACITY:6CENSUS: 6DATE:
11/05/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:40 AM
MET WITH:Licensee/Administrator, Christina RowlandsTIME COMPLETED:
11:15 AM
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Licensing Program Analyst (LPA) Erik Gonzalez Campos arrived unannounced to conduct a Required - 1 Year Inspection at approximately 9:40 AM, and met with licensee/administrator Christina Rowlands. The inspection was focused on the Infection Control procedures and practices of this facility.

Upon entry staff asked LPA to sign-in on visitor sheet. Administrator took LPA's temperature and had LPA fill out COVID screening sheet. At primary entrance LPA observed screening sheets and visitor logs. LPA conducted walk through of the facility with licensee and observed COVID postings throughout. Facility was a comfortable temperature and exits were free from obstructions. Mitigation plan has been submitted and reviewed by Community Care Licensing (CCL).

Hand sanitizer is kept throughout the facility. Per licensee, updated infection control guidelines and PINs are communicated to responsible parties through an on-site information resource binder. Staff have completed Personal Protective Equipment (PPE) and infection control training through local public health. Staff have been N95 fit tested through local public health. High touch surface areas are disinfected daily. Due to current facility census, residents could isolate in their own rooms if they became ill. LPA confirmed licensee has necessary PPE and supplies to support a resident in isolation. Residents have their temperatures taken twice a day. Staff and residents are fully vaccinated. Residents received their COVID booster vaccine and flu vaccine through Rite Aid on November 03, 2021.

Residents' emergency contact information has been updated and licensee confirmed staff are familiar with 911 procedures and protocols. Toxins are secured and inaccessible in locked hallway closet and in a locked kitchen cabinet. Medications are centrally stored in a locked closet making them inaccessible to residents. Last emergency drill was performed in September.

Continued on LIC 809C
SUPERVISOR'S NAME: Kimberley MotaTELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Erik Gonzalez CamposTELEPHONE: (707) 588-5026
LICENSING EVALUATOR SIGNATURE:

DATE: 11/05/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/05/2021
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, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928
FACILITY NAME: SONOMA OAK TREE HOME
FACILITY NUMBER: 496803864
VISIT DATE: 11/05/2021
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During inspection LPA observed staff and administrator conduct exercises with five residents in the living room.

LPA requested an updated copy of facility liability insurance.

No deficiencies observed during today's inspection.
SUPERVISOR'S NAME: Kimberley MotaTELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Erik Gonzalez CamposTELEPHONE: (707) 588-5026
LICENSING EVALUATOR SIGNATURE:

DATE: 11/05/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/05/2021
LIC809 (FAS) - (06/04)
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