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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496803864
Report Date: 11/21/2022
Date Signed: 11/21/2022 02:33:25 PM


Document Has Been Signed on 11/21/2022 02:33 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
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405



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:
11/21/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:40 PM
MET WITH:Christina Rowlands, AdministratorTIME COMPLETED:
02:40 PM
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Licensing Program Analyst (LPA) Jill Nakagawa arrived unannounced to conduct a Required - 1 Year Inspection at approximately 1:40 PM, 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. Carestaff took LPA's temperature. At primary entrance LPA observed signs about Covid-19, wearing masks and visitor logs. LPA conducted walk through of the facility with and observed COVID postings throughout. Facility was a comfortable temperature and exits were free from obstructions. Mitigation plan, Infection Control Plan, and Monkeypox Control Plan have been submitted and reviewed by Community Care Licensing (CCL).

Hand sanitizer is kept throughout the facility. 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. Licensee has necessary PPE and supplies. Residents have their temperatures taken twice a day. Staff and residents are fully vaccinated. Residents received their latest COVID booster vaccine on November 3, 2022.

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. Sharps are stored in locked drawer in kitchen. Medications are centrally stored in a locked closet making them inaccessible to residents. Last emergency drill was performed in September.

There were no deficiencies found at the time of inspection. No citations issued.
Report reviewed with Administrator.
SUPERVISOR'S NAME: Kimberley MotaTELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Jill NakagawaTELEPHONE: 707-588-5063
LICENSING EVALUATOR SIGNATURE:
DATE: 11/21/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/21/2022
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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