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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496804276
Report Date: 11/18/2025
Date Signed: 11/18/2025 03:29:42 PM

Document Has Been Signed on 11/18/2025 03:29 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:		YESSENIA GRANDEFACILITY TYPE:
740
ADDRESS:19326 SOLANO CTTELEPHONE:
(707) 996-6683
CITY:SONOMASTATE: CAZIP CODE:
95476
CAPACITY: 6CENSUS: 6DATE:
11/18/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:13 AM
MET WITH:Yessenia Grande, licenseeTIME VISIT/
INSPECTION COMPLETED:
03:43 PM
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Licensing Program Analyst (LPA) Christi Coppo arrived unannounced to conduct a required Annual inspection and was greeted by caregiver. Administrator Yessenia Grande arrived later. Facility currently has six (6) residents in care two (2) of which are currently on hospice. Yessenia Grande's Administrator Certificate 6074852740 expires 8/18/27

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. Most food was found to be stored in a safe manner with open items covered. Two apples segments were left uncovered in fruit bowl, fruit flies present. Admin explained that they have chickens and save scraps for them. Admin and LPA discussed getting a food compost bucket to store food scraps. LPA observed kitchen cabinet under sink to contain disinfectants and cleaning supplies. Cabinet has magnetic locking mechanism.

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 121.6 degrees F in the kitchen which is not within the allowable range of 105 to 120 degrees F. However, water temperature measured 106.4 in the main bathroom used by residents and 105.7 in room #4, both of which are within the allowable range of 105
to 120 degrees F. Facility only has one water heater, so facility maintenance worker will work to adjust water temperature so that kitchen temperature remains within regulation.


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NAME OF LICENSING PROGRAM MANAGER: Victoria Bertozzi
NAME OF LICENSING PROGRAM ANALYST: Christi Coppo
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 11/18/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/18/2025
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.

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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: 11/18/2025
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Facility has a garage in which food is stored food, canned goods, an overflow refrigerator and a freezer. Facility stores bird seed and bird feed in the garage. Sunflower seeds were found spread throughout most of the garage and old mattress stored had small area of exposed foam and bedding material. Seeds were found spread all around mattress as well as plastic bags piled behind shelves of canned food. LPA discussed with Admin the presence of seeds and bird seed could present as an attracting factor for rodents. LPA did not observe any rodent dropping in the garage. However, LPA and Admin observed rodent droppings inside the facility in the hallway closet (deficiency cited, see 809D).

The outside backyard has 3 video camera, which do have audio functionality but the licensee has disabled the audio. Additionally, backyard has a rental unit that does not share any walls with the facility. Premises is rented out and currently has tenants. Tenants do not have access to the facility, but do utilize the garage during specific hours: between 6:00pm and 10:00pm only. The door to the garage from inside the facility has a locking function such that one cannot enter from the garage into the kitchen.

Fire extinguishers were last inspected 08/19/25. Smoke/Carbon Monoxide detectors located throughout the facility are operational. Facility’s last quarterly disaster drill was conducted in August. LPA and Admin discussed that drills must be done quarterly.

At approximately 12:00pm LPA conducted a review of five (5) out of five (5) staff files. Staff S1, S2, S3, and S4 do not have the required hours of training completed (deficiency cited, see 809D).

At approximately 1:00pm LPA conducted review of six (6) out of six (6) resident files. LPA advised that any and all orders for thickener, crushed meds, half rails, and postural supports must be maintained in the residents' files.



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

DATE: 11/18/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/18/2025
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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: 11/18/2025
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At approximately 2:00pm LPA and caregiver conducted a spot check of medication and medication records. Medication is centrally stored in a locked cabinet. No deficiencies cited.

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

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: 11/18/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/18/2025
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 11/18/2025 03:29 PM - It Cannot Be Edited


Created By: Christi Coppo On 11/18/2025 at 03:02 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 PLACE
FACILITY NUMBER: 496804276

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/18/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87303(a)
Maintenance and Operation
(a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA and Admin observation, the licensee did not comply with the section cited above in that facility had rodent dropping in closet, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/02/2025
Plan of Correction
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Facility to provide work order and paid invoice for pest extermination by plan of correction die date.
Type B
Section Cited
HSC
1569.625(b)(2)
Other Provisions
(2) In addition to paragraph (1), training requirements shall also include an additional 20 hours annually, eight hours of which shall be dementia care training, as required by subdivision (a) of Section 1569.626, and four hours of which shall be specific to postural supports, restricted health conditions, and hospice care, as required by subdivision (a) of Section 1569.696. This training shall be administered on the job, or in a classroom setting, or both, and may include online training.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA and Admin observation and record review, the licensee did not comply with the section cited above in that S1, S2, S3, and S4 did not have the required hours of training completed, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/02/2025
Plan of Correction
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Facility to submit training certificate for S1, S2, S3, and S4 by plan of correction.
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: 11/18/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/18/2025


LIC809 (FAS) - (06/04)
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