496803864-11-5-2024-21-AS-CCOO-DAQTWB-20241105140514

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 496803864
Report Date: 11/05/2024
Date Signed: 11/05/2024 02:05:31 PM

Document Has Been Signed on 11/05/2024 02:05 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 HOME		FACILITY NUMBER:	496803864
ADMINISTRATOR/ DIRECTOR:	BRUK, DINA		FACILITY TYPE:	740
ADDRESS:	425 ARBOR AVE		TELEPHONE:	(707) 287-6214
CITY:	SONOMA	STATE: CA	ZIP CODE:	95476
CAPACITY: 6	TOTAL ENROLLED CHILDREN: 0	CENSUS: 6	DATE:	11/05/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	09:14 AM
MET WITH:	Dina Bruk, Administrator		TIME VISIT/ INSPECTION COMPLETED:	02:20 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analyst (LPA) Christi Coppo arrived unannounced to conduct a required Annual inspection and was greeted by caregiver. Administrator Dina Bruk arrived later. At approximately 10:00am 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. Hall closet containing cleaning supplies was locked. Kitchen drawer with sharp knives inaccessible to residents in care. 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 bathroom had required bath mat and grab bar. Water temperature in sink accessible to residents in care measured at 105.3 and 106.3 degrees F which is within the allowable range of 105 to 120 degrees F. Fire extinguishers were last inspected 7/29/24. Smoke/Carbon Monoxide detectors located throughout the facility are hardwired and last serviced by Stryker Fire and Security in October of 2024. Facility’s last quarterly disaster drills were conducted 10/03/2024. Facility has a backup generator for use during a power outage. At approximately 11:30am LPA conducted a review of 6 resident records. No deficiencies cited. At approximately 12:00pm LPA conducted review of 5 staff records. LPA discussed age of training materials. CCO materials used for training are dated 2015. LPA and Admin discussed updating the training materials to be more current and/or enrolling the staff in an approved vendor and conducting online training. Continued on 809C...

Victoria Bertozzi	TELEPHONE: (707) 588-5059
Christi Coppo	TELEPHONE: (707) 588-5054
	DATE: 11/05/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/05/2024

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 HOME	FACILITY NUMBER: 496803864
	VISIT DATE: 11/05/2024

NARRATIVE

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Continued from 809...

LPA found that S1 and S2 did not have fingerprint clearance and as such were not associated to the facility. LPA discussed with Admin the letter from CDSS that indicates fingerprint clearance and that the letter from the DOJ is not proof of fingerprint clearance. LPA discussed with Admin periodically checking the Guardian facility roster to ensure all staff employed and working are present on roster. LPA discussed with Admin that both S1 and S2 may not work at the facility or be present at the facility in any capacity until fingerprint clearance is obtained (deficiency cited, see 809D **LIC421BG civil penalty assessed**)

At approximately 2:00pm LPA and Admin conducted a spot check of medication. Medication is centrally stored in a locked cabinet. No deficiencies cited.

Dina Bruk Administrator Certificate 6071278740 expires 7/17/2026. All fees are current as of this time.

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

Deficiencies cited from the California Code of Regulations, Title 22, Division 6 of California Regulation and the Health and Safety Code. Appeal rights given and discussed with Admin. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties.

Exit interview conducted with Administrator and a copy of this report was given.

SUPERVISOR'S NAME: Victoria Bertozzi	TELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Christi Coppo	TELEPHONE: (707) 588-5054
LICENSING EVALUATOR SIGNATURE:	DATE: 11/05/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/05/2024

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 11/05/2024 02:05 PM - It Cannot Be Edited

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 HOME	FACILITY NUMBER: 496803864
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 11/05/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Section Cited

Criminal Record Clearance

(e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility: This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on LPA and Admin record review, the licensee did not comply with the section cited above in that S1 and S2 did not have fingerprint clearance, which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 11/06/2024
	Plan of Correction
1 2 3 4	Admin to submit to CCL LIC9098 self-certifying that S1 and S2 will not work or be present at the facility in any capacity until fingerprint clearance is obtained. Once fingerprint clearance is obtained Admin to notify CCL and confirm S1 and S2 are also associated to the facility before working or being present at the facility in any capacity.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

Victoria Bertozzi	TELEPHONE: (707) 588-5059
Christi Coppo	TELEPHONE: (707) 588-5054
	DATE: 11/05/2024

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/05/2024

LIC809 (FAS) - (06/04)

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