<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 210102765
Report Date: 04/01/2025
Date Signed: 04/01/2025 03:09:57 PM

Document Has Been Signed on 04/01/2025 03:09 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
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME:CEDARS OF MARIN ROSS CAMPUS, THEFACILITY NUMBER:
210102765
ADMINISTRATOR/
DIRECTOR:		ANDERSON, STACYFACILITY TYPE:
735
ADDRESS:115 UPPER ROADTELEPHONE:
(415) 454-5310
CITY:ROSSSTATE: CAZIP CODE:
94957
CAPACITY: 55CENSUS: 47DATE:
04/01/2025
TYPE OF VISIT:Case Management - Annual ContinuationUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:50 AM
MET WITH:Rodric Robinson, Director Residential Services & Stacy Anderson, AdministratorTIME VISIT/
INSPECTION COMPLETED:
01:50 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
On 4/1/2025 at approx 9:50am Licensing Program Analyst (LPA) Hansen arrived unannounced to complete annual Inspection of the Cedars of Marin Ross Campus that initiated 3/27/2025. LPA met with Director of Residential Services, Rodric Robinson & Administrator, Stacy Anderson.

On 3/27/2025 during tour facility water temperature in McIvor and Collins Halls were out of acceptable range. At today's inspection LPA re-tested water temperatures in these halls which measured between 121.6 and 123.6 degrees F, falling out of regulations between 105 and 120 degrees F in 4 out of 4 faucets (in McIvor & Collins Halls)(see LIC 809D).

All buildings have functioning smoke detectors, carbon monoxide detectors, pull station fire alarms with audio/visual alarms and sprinklers. The fire alarms are tested by a contractor, Fire King Fire Protection, Inc, last inspection 3/4/2025. There was a water issue with the sprinkler system that is being fixed and the facility will submit updated fire clearance once received. Disaster Drills are conducted monthly and are documented, last 3/31/2025.

LPA reviewed 5 Client records. Based on record review at 11:30 AM with Administrator 5 out of 5 clients files contained medical assessments (602’s) & current Needs and Service plans/ISP's per Title 22 regulations within one year.

Continue on LIC809-C
NAME OF LICENSING PROGRAM MANAGER: Bethany Moellers
NAME OF LICENSING PROGRAM ANALYST: Shannan Hansen
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 04/01/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/01/2025
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 6
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)
Page: 2 of 6
Document Has Been Signed on 04/01/2025 03:09 PM - It Cannot Be Edited


Created By: Shannan Hansen On 04/01/2025 at 01:09 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: CEDARS OF MARIN ROSS CAMPUS, THE
FACILITY NUMBER: 210102765

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/01/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80088(e)(1)
Fixtures, Furniture, Equipment, and Supplies
(e) Faucets used by clients for personal care such as shaving and grooming shall deliver hot water. (1) Hot water temperature controls shall be maintained to automatically regulate temperature of hot water delivered to plumbing fixtures used by clients to attain a hot water temperature of not less than 105 degrees F (40.5 degrees C) and not more than 120 degrees F (48.8 degrees C).

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation with staff, the licensee did not comply with the section cited above in 4 out of 4 facility faucits (2 in McIvor & 2 in Collins Hall) measured between 121.6 & 123.6 degrees F after requesting water temperature be turned down 5 days prior at initial inspection, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 04/02/2025
Plan of Correction
1
2
3
4
 Facility agrees to keep a daily log of temperature for 2 weeks (4/16/25). Facility to send in written statement they understand regulation 80088(e)(1). by POC due date 4/2/2025 with log showing water temp is within regulation to clear citation.
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.
Bethany Moellers
NAME OF LICENSING PROGRAM MANAGER:
Shannan Hansen
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 04/01/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/01/2025


LIC809 (FAS) - (06/04)
Page: 3 of 6
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME: CEDARS OF MARIN ROSS CAMPUS, THE
FACILITY NUMBER: 210102765
VISIT DATE: 04/01/2025
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
26
27
28
29
30
31
32
Continued from LIC809

At approximately 12:30 PM LPA reviewed 5 of 5 Staff records, which were all found to be well organized, thorough and contained the required documentation. First aid and CPR certification, and all other required traings were current in staff files reviewed. P&I monies were documented, secure and not commingled. All staff and others needing background clearance and associated have been.

Appeal of Rights Given.

The following deficiencies were observed (see LIC 809D) and cited from the California Code of Regulations, Title 22, Division 6 of California Regulation. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties. Exit interview conducted and appeal of rights provided


Updated copies of the following documents were requested for facility file and are to be submitted to CCL by 4/18/2025:

LIC308- Designation of Responsibility (if changes)
LIC610D- Disaster Plan (if changes)
LIC400-Affidavit Regarding Client Cash Resources
Copy of Surity Bond
NAME OF LICENSING PROGRAM MANAGER: Bethany Moellers
NAME OF LICENSING PROGRAM ANALYST: Shannan Hansen
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 04/01/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/01/2025
LIC809 (FAS) - (06/04)
Page: 6 of 6