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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 210102765
Report Date: 03/26/2026
Date Signed: 03/26/2026 03:50:05 PM

Document Has Been Signed on 03/26/2026 03:50 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: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: 49DATE:
03/26/2026
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:40 AM
MET WITH:Rodric Robinson, Director Residential Services &
Stacy Anderson, Administrator		TIME VISIT/
INSPECTION COMPLETED:
04:00 PM
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At approximately 9:40 AM, Licensing Program Analyst (LPA) Robert Frank arrived unannounced to conduct a Required 1 Year inspection and was greeted by Director of Residential Services (DRS) Rodric Robinson and Administrator Stacy Anderson. The Cedars of Marin Ross Campus is Licensed as an Adult Residential Facility (ARF). The facility consists of three buildings divided into four halls. The facility has an approved fire clearance for fifty-five (55) clients in total, nineteen (19) of whom may be non-ambulatory. The facility has a hospice waiver for two (2) Clients between the ages of eighteen (18) and fifty-nine (59). McIvor Hall and Collins Hall are in one building. McIvor Hall houses six (6) clients. Collins Hall houses six (6) clients, six (6) of whom may be non-ambulatory. Peterson Hall houses a total of twenty (20) clients, nine (9) of whom may be non-ambulatory. Administrative and medical offices are also located in Peterson Hall. Pope Hall houses fifteen (15) clients, four (4) of whom may be non-ambulatory. Upon arrival, LPA was informed that there were forty-nine (49) clients in care. At approximately 9:55 AM, LPA reviewed the Facility's Staff Roster and observed that all staff on-site were background cleared and associated to the facility per regulation.

At approximately 10:20 AM, LPA toured the facility with DRS Robinson & Administrator Anderson. All exits were clear and unobstructed. Fire extinguishers in all halls were last serviced and tagged ion 2/24/2026. The fire alarm system in all halls was inspected in 11/2025. The facility was sufficiently lighted. LPA inspected a sample of client bedrooms in all halls and observed all to have sufficient lighting and furnishings as required per Title 22 Regulations. Each hall has a small kitchen area. Clients may eat there or in the central dining room located in Peterson Hall The facility had a sufficient supply of both perishable and nonperishable foods as required by Title 22 Regulations. Snacks were available for clients in all halls. There was an appropriate supply of cleaning products, linens, hygiene products and paper products available for clients. Toxins were observed to be stored inaccessible to clients. Facility has an infection control plan as required. Continued on 809-C...
NAME OF LICENSING PROGRAM MANAGER: Victoria Bertozzi
NAME OF LICENSING PROGRAM ANALYST: Robert Frank
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 03/26/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/26/2026
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)
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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: CEDARS OF MARIN ROSS CAMPUS, THE
FACILITY NUMBER: 210102765
VISIT DATE: 03/26/2026
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...Continued from 809

The facility has a required emergency disaster plan. The facility is conducting fire and emergency drills monthly. The last set of Disaster Drills was held on 3/20/2026. The facility does have emergency food and supplies to meet the "72 hour shelter in place" requirements. Hot water temperatures for a sample sinks in facility were observed to be within Title 22 regulations of 105 to 120 degrees Fahrenheit. Facility smoke detectors and carbon monoxide detectors were tested and observed to be operational. The fire alarm system was also tested and observed to be operational. Evacuation chairs were observed in stairwells in Peterson Hall.

LPA audited Medication for three (3) clients in each hall for a total of twelve (12) clients. Three (3) of twelve (12) clients (clients C1, C2 & C3) had prescribed medications that were observed not be listed in the Centrally Stored Medication and Destruction Records as required by regulation. Two (2) of twelve (12) clients (clients C2 & C3) prescribed medications were observed not to have the prescription fill date entered the Centrally Stored Medication and Destruction Records. These deficiencies will be cited. LPA observed all other medications to be centrally stored, secure and with proper documentation.
At approximately 12:50 PM, LPA reviewed five (5) client files. Five (5) of five (5) client files were observed to be well organized and thorough with all required documentation. LPA reviewed five (5) staff files. Staff files have been digitized. Five (5) of five (5) staff files were observed to be well organized with all required documentation including First Aid and CPR certification and proper training documentation. Client’s monies for personal and incidental (P&I) items were audited and observed to be secure and to balance to P&I logs.

Stacy Anderson’s Administrator Certification 7009007735 is current with an expiration date of 2/26/2028.

LPA requested the following documents be submitted to Community Care Licensing by 4/26/2026:


LIC 610D Emergency Disaster Plan

Deficiencies are cited from the California Code of Regulations (CCRs), and/or the Health and Safety Code. Failure to correct the cited deficiency, on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Exit interview conducted. Copy of report, LIC-809D, Plan of Corrections, LIC-811 Confidential Names and Appeal Rights discussed and provided to Administrator Anderson. Signature on form confirms receipt of documents.
NAME OF LICENSING PROGRAM MANAGER: Victoria Bertozzi
NAME OF LICENSING PROGRAM ANALYST: Robert Frank
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 03/26/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/26/2026
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 03/26/2026 03:50 PM - It Cannot Be Edited


Created By: Robert Frank On 03/26/2026 at 03:22 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: 03/26/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80075(k)(7)
Health-Related Services
(k) The following requirements shall apply to medications which are centrally stored: (7) The licensee shall ensure the maintenance, for each client, of a record of centrally stored prescription medications which is retained for at least one year and includes the following:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation & record review)], the licensee did not comply with the section cited above in that three (3) of twelve (12) clients (clients C1, C2 & C3) had prescribed medications that were observed not be listed in the Centrally Stored Medication and Destruction Records which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 03/27/2026
Plan of Correction
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Licensee or Administrator to provide proof that all staff members who handle Clients Medication have undergone training in Medication Intake and Maintaining the Centrally Stored Medication and Destruction Records to Community Care Licensing by the POC due Date of 3/27/2026.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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:
Robert Frank
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 03/26/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/26/2026


LIC809 (FAS) - (06/04)
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