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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496803864
Report Date: 12/20/2023
Date Signed: 12/20/2023 01:56:26 PM


Document Has Been Signed on 12/20/2023 01:56 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:SHANTI RAGLANDFACILITY TYPE:
740
ADDRESS:425 ARBOR AVETELEPHONE:
(707) 287-6214
CITY:SONOMASTATE: CAZIP CODE:
95476
CAPACITY:6CENSUS: 6DATE:
12/20/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Christina Ragland (Licensee)TIME COMPLETED:
02:00 PM
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Licensing Program Analyst (LPA) Cuadra conducted an unannounced Required - 1 Year annual inspection and met with Licensee, Christina Rowlands. There are residents with a diagnosis of dementia and no residents were receiving hospice care at the time of the visit. Required postings were observed. Facility contact information was reviewed. Fees are current at the time of visit.

Beginning at 10:10 AM, LPA/Licensee toured the outside and inside of the facility were found to be a comfortable temperature. Exits and pathways were free from obstructions. Hot water temperature measured between 112.8, 105.1 and 113.4 F in faucets used by residents which is within regulation of 105 to 120 degrees F. LPA observed at least a minimum of a 2 day supply of perishable and 7 day supply of non-perishable food quantity and quality stored in a safe manner for residents in care and staff as well as an emergency food supply. Bathrooms contained necessary grab bars and non-slip floor/mats. Toxins were observed to be inaccessible for residents. Medications are centrally stored in a locked office. Fire extinguishers were current and charged as of July 2023. Smoke detector and carbon monoxide were tested and operational. A disaster drill was conducted on September 2023. Administrator Shanti Ragland Certificate 6054993740 expires 1/26/2024.

LPA initiated file review at 11:00am six resident and five staff records. all residents care plans and medical assessments has been updated within the last 12 months. Three staff records were reviewed. Staff have CPR/1st aid certificate and does have 20 hours of required annual training on file. A spot check of Medication and medication records was also conducted.
Licensee agrees to submit the following documents updates to CCL by 12/28/2023:LIC308 - Designation of Administrator Responsibility, LIC500 - Personnel Report, Updated Liability Insurance Certificate, Control of property and LIC610E - Emergency Disaster Plan & Updated Evacuation Plan.
No deficiencies cited during today's visit. Exit interview was conducted with Licensee and a copy of the report was emailed due to technical issues with LPA's printer.
SUPERVISOR'S NAME: Bethany MoellersTELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Marisol CuadraTELEPHONE: (707) 588-5078
LICENSING EVALUATOR SIGNATURE:
DATE: 12/20/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/20/2023
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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