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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496804259
Report Date: 01/06/2026
Date Signed: 01/06/2026 03:22:18 PM

Document Has Been Signed on 01/06/2026 03:22 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 HOMEFACILITY NUMBER:
496804259
ADMINISTRATOR/
DIRECTOR:		BRUK, DINAFACILITY TYPE:
740
ADDRESS:425 ARBOR AVETELEPHONE:
(707) 996-4706
CITY:SONOMASTATE: CAZIP CODE:
95476
CAPACITY: 6CENSUS: 6DATE:
01/06/2026
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:13 AM
MET WITH:Licensee, Dina BrukTIME VISIT/
INSPECTION COMPLETED:
03:36 PM
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Licensing Program Analyst (LPA) Christi Coppo arrived unannounced to conduct a required Annual inspection and was greeted by caregiver. Licensee Dina Bruk arrived later. Administrator 6071278740 expires 7/17/2026. Facility currently has six (6) residents in care, two of which are currently on hospice.

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 and labeled with opened dates present. All cleaning products are locked in a closet. Laundry soaps are located in the laundry room and are 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 bathrooms had required bath mats and grab bars. Water temperature in sinks measured at 120.9 degrees F in the kitchen and 119.1 degrees F in room #2, 118.1 degrees F in room #3, and 110.4 in room #6, all except for the kitchen temperature are within the allowable range of 105 to 120 degrees F. Facility has another bathroom used by staff only. Licensee will work to get water in compliance with regulation as 120.9 is slightly outside of the requirement of 105 to 120 degrees F.

Fire extinguishers were last inspected 07/23/2025. Smoke/Carbon Monoxide detectors located throughout the facility were tested and operational. Sprinklers are hardwired and last serviced by a vendor in August of 2025.
Continued on 809C...
NAME OF LICENSING PROGRAM MANAGER: Victoria Bertozzi
NAME OF LICENSING PROGRAM ANALYST: Christi Coppo
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 01/06/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/06/2026
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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California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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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: 496804259
VISIT DATE: 01/06/2026
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Facility’s last quarterly disaster drill was conducted on 9/30/25. Facility has a backup generator for use during a power outage.

Facility continues to rent separate residence in back of facility property. Residence does not share any walls with the facility. The tenants do not access the facility; however, they do use the stacked washer and dryer in the garage. Residents do not have access to the garage. Garage door from inside facility has locking function such that when it is locked it cannot be opened from either side of the door. LPA and caregiver tested locking function. LPA could not access facility from the garage when door was locked.

At approximately 11:30am LPA conducted a review of six (6) staff records. Training videos are dated 2010, 2011, 2012, and 2015 respectively. Per licensee, dementia care training material is newer but LPA did not observe dates of publication. LPA observed some training dates present for staff to be on their scheduled days off. Per licensee, training dates reported on training log were completed by both the staff and by her. LPA discussed with licensee providing updated materials for training, especially for dementia care. LPA discussed with licensee importance of maintaining accuracy of training records. LPA discussed with licensee absence of medication training test required per Health and Safety Code (HSC)1569.69. Facility does not employ a designated Med Tech for each shift, so all caregivers administer medication. LPA discussed with licensee HSC requirement of medication test and that this test is required of all staff administering medication. S1 did not have TB clearance on file (deficiency cited, see 809D).

At approximately 1:00pm LPA reviewed six (6) out of six (6) resident files. Files complete.


At approximately 2:15pm LPA and conducted a spot check of medication and medication records. Medication is centrally stored in a locked closet. LPA and licensee discussed medication management requirements regarding the Centrally Stored Medication Log (CSML) and making sure that everything listed on current physician orders is also listed on the CSML, including PRNs. Current physician orders should be signed. If a medication is on the current physician's orders but not listed on the CSML then a discontinuation order must be maintained in the file. LPA reviewed PRN MAR, PRN MAR in compliance with regulation.

Continued on 809C(2)...
NAME OF LICENSING PROGRAM MANAGER: Victoria Bertozzi
NAME OF LICENSING PROGRAM ANALYST: Christi Coppo
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 01/06/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/06/2026
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: 496804259
VISIT DATE: 01/06/2026
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Deficiencies cited from the California Code of Regulations, Title 22, Division 6 of California Regulation and the Health and Safety Code. Appeal rights given. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties. Exit interview conducted with licensee and a copy of this report was given.
NAME OF LICENSING PROGRAM MANAGER: Victoria Bertozzi
NAME OF LICENSING PROGRAM ANALYST: Christi Coppo
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 01/06/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/06/2026
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 01/06/2026 03:22 PM - It Cannot Be Edited


Created By: Christi Coppo On 01/06/2026 at 02:49 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: SONOMA OAK TREE HOME
FACILITY NUMBER: 496804259

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/06/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87411(f)
Personnel Requirements - General
(f) All personnel, including the licensee and administrator, shall be in good health, and physically and mentally capable of performing assigned tasks. Good physical health shall be verified by a health screening, including a chest x-ray or an intradermal test, performed by a physician not more than six (6) months prior to or seven (7) days after employment or licensure. A report shall be made of each screening, signed by the examining physician. The report shall indicate whether the person is physically qualified to perform the duties to be assigned, and whether he/she has any health condition that would create a hazard to him/herself, other staff members or residents. A signed statement shall be obtained from each volunteer affirming that he/she is in good health.Personnel with evidence of physical illness or emotional instability that poses a significant threat to the well-being of residents shall be relieved of their duties.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA and licensee record review, the licensee did not comply with the section cited above in that S1 did not have TB clearance on file, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 01/27/2026
Plan of Correction
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Facility to submit proof of TB clearance for S1 by the plan of correction due date.

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
NAME OF LICENSING PROGRAM MANAGER:
Christi Coppo
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 01/06/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/06/2026


LIC809 (FAS) - (06/04)
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