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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496804276
Report Date: 11/15/2024
Date Signed: 11/15/2024 12:55:46 PM

Document Has Been Signed on 11/15/2024 12:55 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 PLACEFACILITY NUMBER:
496804276
ADMINISTRATOR/
DIRECTOR:
MORENO, RUBYFACILITY TYPE:
740
ADDRESS:19326 SOLANO CTTELEPHONE:
(707) 695-2426
CITY:SONOMASTATE: CAZIP CODE:
95476
CAPACITY: 6CENSUS: 6DATE:
11/15/2024
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:43 AM
MET WITH:Yessenia Grande, ApplicantTIME VISIT/
INSPECTION COMPLETED:
12:40 PM
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Licensing Program Analyst (LPA) Christi Coppo arrived unannounced to conduct a pre-licensing inspection and was greeted by caregiver. Applicant, Yessenia Grande arrived later at approximately 10:00am. Applicant was able to show proof of pending initial Administrator certification: certificate #6074852740 is pending but status shows as payment received and application received 9/30/24.

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. LPA observed within regulation emergency supply of non-perishable food. Locked cabinet stores toxins and cleaning products. One locked drawer is dedicated for sharp knives.

Facility is a one story residence with four bedrooms, three full bathrooms, and dining and living room common areas. All resident rooms are furnished per regulation with a bed, lamp, dresser, chair and bedside table.

Smoke and carbon monoxide detectors present and functioning. Facility has two fire extinguishers, last inspected 8/8/24. LPA observed all required postings and posters present. Applicant advised that facility will use personal van or community service to provide emergency transport services in the event of a disaster.

Water temperatures read at: 119.8 F in kitchen, 112.7 F in main bath, 108.1 F in room #3, and 108.5 F in room #4 all which are within regulation of 105 & 120 degrees F. LPA and Applicant discussed keeping an eye on the water temperature in the kitchen to be sure it doesn't go over 120 degrees F. Applicant agrees to check and turn the water heater down slightly should it read over 120 degrees F.


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SUPERVISORS NAME: Victoria Bertozzi
LICENSING EVALUATOR NAME: Christi Coppo
LICENSING EVALUATOR SIGNATURE: DATE: 11/15/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/15/2024
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 PLACE
FACILITY NUMBER: 496804276
VISIT DATE: 11/15/2024
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The following items to be corrected prior to LPA submission of facility's application for approval:
  • All trash cans in rooms and bathrooms need tight fitting covers
  • Shower in main bath needs non-skid strips or mat
  • Vanity in room #3 needs left hand side bottom drawer fixed
  • Bathroom in room #4 needs right hand side bottom drawer of vanity fixed, non-skid strips or mat in shower, and left side overhead lamp bulb replaced/repaired, right hand side sink needs to display the correct indictor for hot and cold water. Applicant to either replace faucet indicator or put sign up indicating hot and cold placement for faucet.
  • Room #4 needs an overhead light or lamp bright enough to light the room

Applicant to provide photos and/or videos of repaired/replaced items. Once acceptable photographic and/or video proof of corrections is received by CCL, LPA will submit facility's application for approval.



Comp III reviewed and exit interview conducted with Applicant and a copy of this report given.
SUPERVISORS NAME: Victoria Bertozzi
LICENSING EVALUATOR NAME: Christi Coppo
LICENSING EVALUATOR SIGNATURE:

DATE: 11/15/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/15/2024
LIC809 (FAS) - (06/04)
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