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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 210109022
Report Date: 07/03/2025
Date Signed: 07/03/2025 10:15:38 AM

Document Has Been Signed on 07/03/2025 10:15 AM - 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:NOVATO RESIDENTIAL SUPPORT SERVICESFACILITY NUMBER:
210109022
ADMINISTRATOR/
DIRECTOR:		JOHN AHRENSFACILITY TYPE:
735
ADDRESS:1333 SEVENTH STREETTELEPHONE:
4158977195
CITY:NOVATOSTATE: CAZIP CODE:
94945
CAPACITY: 15CENSUS: 15DATE:
07/03/2025
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:30 AM
MET WITH: Mental Health Counselor, Debora SmithTIME VISIT/
INSPECTION COMPLETED:
10:30 AM
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
Licensing Program Analyst (LPA) Hansen was at facility delivering complaint findings and conducted a case management meeting with Mental Health Counselor, Debora Smith. Staff contacted Assistant Program Director Suhay Rivas for approval to sign for documents today. The case management is due to incident reports regarding medication errors submitted to Community Care Licensing (CCL) on 4/28/2025, 5/14/2025 and two on 6/19/2025.

CCL received a self reported incident report reporting on 4/28/2025, that on 4/22/25 at approximately 7 pm C1 was sent out due to panic attack. After evaluation C1 was admitted to ER due to elevated blood sugar levels. Further evaluation revealed doctors’ orders of daily blood sugar monitoring logs 5/2024 had not been implemented or documented. During today’s inspection LPA was informed C1’s blood sugar monitoring logs are being logged 2X per day by staff after C1 conducts test.

LPA obtained additional information regarding an incident that occurred on 4/29/2025 involving C2 (report not submitted to CCL until 5/14/2025, 15 days later -see LIC809-D reporting requirements 80061(b) ). At approximately 8am staff (S1) inadvertently administered C1’s 8 pm medications during AM distribution and did not discover until pm rounds, all appropriate parties were contacted, no adverse side effects observed. Report also indicates, S1 completed refresher training on distribution of medications. Assistant Program Dir. will submit training to CCL.

LPA followed up on an incident submitted to CCL on 6/19/2025 for an incident that occurred on 6/15/2025 when at approximately 7am S2 inadvertently give C3 another client’s morning medications. Appropriate parties notified. 911 arrived shortly after, assessed C3, and offered to transport to ER for observation. C3, not conserved, refused transport, safety monitoring plan put in place.

Continue on LIC809-C

NAME OF LICENSING PROGRAM MANAGER: Bethany Moellers
NAME OF LICENSING PROGRAM ANALYST: Shannan Hansen
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 07/03/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/03/2025
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 4
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 4
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: NOVATO RESIDENTIAL SUPPORT SERVICES
FACILITY NUMBER: 210109022
VISIT DATE: 07/03/2025
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:

No adverse side effects observed. S2 received retraining on medication disbursement and overdose medication policy. Assistant Program Director will submit obtained medication training for S2 to CCL.


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.

Exit interview conducted with Mental Health Counselor and copy of documents provided.

NAME OF LICENSING PROGRAM MANAGER: Bethany Moellers
NAME OF LICENSING PROGRAM ANALYST: Shannan Hansen
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 07/03/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/03/2025
LIC809 (FAS) - (06/04)
Page: 3 of 4
Document Has Been Signed on 07/03/2025 10:15 AM - It Cannot Be Edited


Created By: Shannan Hansen On 07/03/2025 at 08:54 AM
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: NOVATO RESIDENTIAL SUPPORT SERVICES
FACILITY NUMBER: 210109022

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/03/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
07/07/2025
Section Cited
CCR
80075(b)(5)(B)

1
2
3
4
5
6
7
80075(b)(5)(b) Health Related Services: (b) Clients shall be assisted as needed with self-administration of prescription & nonprescription medications. (5)..., providing all of the following requirements are met: (B) Once ordered by the physician the medication is given according to the physician's directions. This requirement was not met as evidenced by:
1
2
3
4
5
6
7
The facility submitted proof of staff trainings for medication mgmt regarding updated protocol to help reduce medication errors. The facility is keeping 2X per day logs of C1's blood suger reading, For C2 & C3 incidents, Asst Program Mgr will submit training and agreed to submit a self-certification form
8
9
10
11
12
13
14
Based on interviews with staff and records review, facility staff did not ensure that C1 (was not having daily blood sugar logged), C2 (was given AM meds during AM), & C3 ( given another clients medications) doctor’s orders were followed . This poses an immediate health, safety and personal rights risk to clients in care.
8
9
10
11
12
13
14
LIC9098 ensuring that clients will be assisted with prescribed medication as prescribed by their physician by POC due date.7/7/2025
Type B
07/11/2025
Section Cited
CCR80061(b)

1
2
3
4
5
6
7
80061(b) Reporting Requirements: ...In addition, a written report containing the information specified in (2) below shall be submitted to the licensing agency within seven days following the occurrence of such event.. This was not met as evidence by:**
1
2
3
4
5
6
7
Program Director to submit LIC9098 indicating that they have reviewed and understand Regulation 80061, Reporting Requirements. LIC9098 to be submitted to CCLD by 7/11/2025. In addition, Administrator to provide plan of action on how facility will remain in
8
9
10
11
12
13
14
 Facility did not notify and submit written
incident report to CCLD based on reporting requirements timeframes.incident that occurred on 4/29/2025 not reported until 5/14/2025, 15 days later. This serves as a potential health & safety risk to clients.
8
9
10
11
12
13
14
compliance with reporting requirements. Written statement to be submitted by POC date 7/11/2025.
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: 07/03/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/03/2025


LIC809 (FAS) - (06/04)
Page: 4 of 4