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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496803864
Report Date: 11/09/2021
Date Signed: 11/09/2021 11:30:25 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:
11/09/2021
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Christina RowlandsTIME COMPLETED:
11:30 PM
NARRATIVE
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Licensing Program Analyst Leibert arrived unannounced and spoke with Administrator Rowlands. During the course of an investigation of a complaint, LPA noted deficiency involving medications. A medication prescribed for R1 was initially written for 25mg twice a day and later changed to 25 mg once a day on or about 7/3/2019. Facility records continued to reflex the original order, 25 mg twice a day. Administrator states that, despite the written record error, the medication was administered as ordered.


The following deficiencies were observed (see LIC 809D) and 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 and appeal of rights provided.
SUPERVISOR'S NAME: Carla MartinezTELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: David LeibertTELEPHONE: (707) 588-5086
LICENSING EVALUATOR SIGNATURE:

DATE: 11/09/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/09/2021
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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/09/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
11/11/2021
Section Cited

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87465(h)(6) INCIDENTAL MEDICAL AND DENTAL CARE. The licensee shall be responsible for assuring that a record of centrally stored prescription medications for each resident is maintained for at least one year....Based upon observations and records reviewed, this requirement has not been met as evidenced by:
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Dosage information for medication prescribed for R1 was incorrectly logged into the facility's Centrally Stored Medication Record. This posed an immediate risk to the safety and health of the resident in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Carla MartinezTELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: David LeibertTELEPHONE: (707) 588-5086
LICENSING EVALUATOR SIGNATURE:
DATE: 11/09/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/09/2021
LIC809 (FAS) - (06/04)
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