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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496804259
Report Date: 12/19/2024
Date Signed: 12/19/2024 10:55:17 AM

Document Has Been Signed on 12/19/2024 10:55 AM - 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 HOMEFACILITY NUMBER:
496804259
ADMINISTRATOR/
DIRECTOR:		BRUK, DINAFACILITY TYPE:
740
ADDRESS:425 ARBOR AVETELEPHONE:
(707) 996-4706
CITY:SONOMASTATE: CAZIP CODE:
95476
CAPACITY: 6CENSUS: 5DATE:
12/19/2024
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:58 AM
MET WITH:CaregiverTIME VISIT/
INSPECTION COMPLETED:
11:09 AM
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Licensing Program Analyst (LPA) Christi Coppo arrived unannounced to conduct a pre-licensing inspection and was greeted by caregiver. Applicant, Dina Bruk was not available to come to the facility. LIC308 designee will sign report. Administrator certification: Dina Bruk Administrator Certificate 6071278740 expires 7/17/2026.

At approximately 9:30am 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. LPA observed, within regulation, emergency supply of non-perishable food. Hall closet containing cleaning supplies was locked. Kitchen drawer with sharp knives inaccessible to residents in care.

Facility is a one story residence with six [6] bedrooms, five [5] full bathrooms, kitchen and dining and living room common areas. Shaded outside area available for recreation and visitation. All resident rooms are furnished per regulation with a bed, lamp, dresser, chair and bedside table. Rooms that have exit sliding doors have alarms present and functioning.

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.

Water temperatures read at: 136.8 degrees F in kitchen, 136.4 degrees F in main bath, 117.5 degrees F in room #6, and 135.8 degrees F in room #4, and 135.9 degrees F. Regulation requires water temperatures to be within 105 & 120 degrees F. LPA advised designee all but the 117.5 reading are outside regulation. Designee will work with applicant turn the water heater down and get the temperature down to within regulation.

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SUPERVISORS NAME: Victoria Bertozzi
LICENSING EVALUATOR NAME: Christi Coppo
LICENSING EVALUATOR SIGNATURE: DATE: 12/19/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/19/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2
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: 496804259
VISIT DATE: 12/19/2024
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Separate residence with private tenant located in the back of the facility. Residence does not share any walls with the facility. The tenant does not access the facility; however, they do use the stacked washer and dryer in the garage. Residents do not have access to the garage.

The following item needs to be corrected prior to LPA submission of facility's application for approval: water temperature throughout the facility must be within regulation of 105 & 120 degrees F. Applicant to provide photos of temperature readings for the following: kitchen, hall main bath, and rooms #6, #4, and #2 that show water temperature within regulation. Once acceptable photographic proof is received by CCL, LPA will submit facility's application for approval.

Comp III reviewed. Exit interview conducted with caregiver and copy of report given
SUPERVISORS NAME: Victoria Bertozzi
LICENSING EVALUATOR NAME: Christi Coppo
LICENSING EVALUATOR SIGNATURE:

DATE: 12/19/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/19/2024
LIC809 (FAS) - (06/04)
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