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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 210109022
Report Date: 11/06/2025
Date Signed: 11/10/2025 08:12:17 AM

Document Has Been Signed on 11/10/2025 08:12 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:
(415) 897-7195
CITY:NOVATOSTATE: CAZIP CODE:
94945
CAPACITY: 15CENSUS: 15DATE:
11/06/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:15 AM
MET WITH:John Ahrens, Program DirectorTIME VISIT/
INSPECTION COMPLETED:
04:25 PM
NARRATIVE
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At approximately 10:15 AM Licensing Program Analyst (LPA) Hansen arrived unannounced to conduct an annual required inspection of facility and was greeted by staff. Administrator, John Ahrens arrived at a later time. Facility’s fire clearance granted for 15 Ambulatory clients. Facility census is 15 although 1 client is currently at family visit.

At approximately 10:20 AM LPA and staff Jenny toured facility, 20 minutes later administrator, John Ahrens arrived to continue tour of facility; facility was found to be at a comfortable temperature with all exits free from obstruction. Client’s bedrooms, common areas, kitchen & food storage areas were inspected. In addition, Bathroom #2 had 2 broken toilet seats (see pictures) and clogged sink with duct tape over basin, although still being used by clients (see LIC809D) Administrator informed getting plumber to service. LPA and Administrator inspected over half of client bedrooms finding many with garbage on the floor, smelling of dirty laundry (see pics) but once advised by Administrator began cleaning. Fire Extinguisher was found to be last charged on 02/07/2025 at the time of the visit. Carbon monoxide detector was not found during the visit (see LIC9102 Advisory Notes). Facility has hard wired smoke detectors and sprinklers with last inspection dated 3/25/2025. Hot water temperature measured between 128.1 degrees F and 136.2 degrees F falling out of Title 22 acceptable regulation of 105 to 120 degrees F in 2 of 3 client’s bathroom while touring facility at 10:30 AM (see LIC809D). There was a sufficient supply of both perishable and nonperishable foods as required by Title 22 Regulations. Food stored in the kitchen refrigerator were properly stored as per regulations on this day at the time of the visit. Toxins are stored in a locked cabinet inside the facility in the hallway; although unlocked at 10:25AM and 11:30AM as observed by LPA and Administrator (see LIC809D). Dangerous items were not stored inaccessible to clients finding unlocked meds and scissors in the office room; and when LPA entered facility there were 2 clients sweeping and cleaning in dining room and kitchen with no staff visible and kitchen knife drawer was unlocked along with cleaning supplies under kitchen sink left unlocked (see pictures & LIC809D).

Continue on LIC809C

NAME OF LICENSING PROGRAM MANAGER: Bethany Moellers
NAME OF LICENSING PROGRAM ANALYST: Shannan Hansen
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 11/06/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/06/2025
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.

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
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME: NOVATO RESIDENTIAL SUPPORT SERVICES
FACILITY NUMBER: 210109022
VISIT DATE: 11/06/2025
NARRATIVE
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Continued from LIC809

There was a supply of cleaners, hygiene products and paper products available for clients. The bathroom designated for clients at the facility were supplied with individual paper towels; hand soap dispenser was available. All client’s bedrooms have lighting & appropriate furnishings.

A review of five clients and a sample review started of five staff records as well as two client’s medications was conducted. LPA reviewed client’s files at 12:05PM and learned that 5 of 6 clients have an updated reappraisal/needs & care plan and physician’s report. However, client C1’s last updated care plan was from 1/7/2016. (see LIC809D) Facility doesn’t handle P&I's for clients. All clients handle their own money.

Medications were centrally stored in a locked medication room in the facility with exception of medications that were placed in the unlocked staff office in the facility (see pictures).

John Ahrens Administrator Certificate # 7031309735 expires on 7/16/2027. Last Disaster Drills conducted on 3/14/2025 (see LIC809D).

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.


LPA unable to complete the Annual Inspection. Annual Continuation Visit to be conducted at a later date.
NAME OF LICENSING PROGRAM MANAGER: Bethany Moellers
NAME OF LICENSING PROGRAM ANALYST: Shannan Hansen
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 11/06/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/06/2025
LIC809 (FAS) - (06/04)
Page: 3 of 9
Document Has Been Signed on 11/10/2025 08:12 AM - It Cannot Be Edited


Created By: Shannan Hansen On 11/06/2025 at 03:36 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: NOVATO RESIDENTIAL SUPPORT SERVICES
FACILITY NUMBER: 210109022

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/06/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80087(a)
Building and Grounds
(a) The facility shall be clean, safe, sanitary and in good repair at all times for the safety and well-being of clients, employees and visitors.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA & Administrator's observation, the licensee did not comply with the section cited above in Bathroom #2 's sink being clogged and toilet seat broken with duct tape on it, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 11/07/2025
Plan of Correction
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Administror to submit plan when pluming service will repair clogged sink along with toilet seat being fixed by POC due date 11/7/2025. Then submit plumbing receipt showing reapair with pictures of new toilet seat.
Type A
Section Cited
CCR
80087(g)(1)
Building and Grounds
(g) Disinfectants, cleaning solutions, poisons, firearms and other items that could pose a danger if readily available to clients shall be stored where inaccessible to clients. (1) Storage areas for poisons, and firearms and other dangerous weapons shall be locked.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA observation, the licensee did not comply with the section cited above finding kitchen knife drawer unlocked along with cabinet under kitchen sink with cleaning solutions unlocked, accessible to clients in care, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 11/07/2025
Plan of Correction
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Administrator to submit plan of when staff training will be conduted by POC due date 11/7/2025. then submit training log with staff signatures/dates/ trainer/ course title by 11/14/2025.
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: 11/06/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/06/2025


LIC809 (FAS) - (06/04)
Page: 4 of 9
Document Has Been Signed on 11/10/2025 08:12 AM - It Cannot Be Edited


Created By: Shannan Hansen On 11/06/2025 at 03:36 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: NOVATO RESIDENTIAL SUPPORT SERVICES
FACILITY NUMBER: 210109022

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/06/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80087(g)
Building and Grounds
(g) Disinfectants, cleaning solutions, poisons, firearms and other items that could pose a danger if readily available to clients shall be stored where inaccessible to clients.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA & Administrator observation, the licensee did not comply with the section cited above as hallway toxin cabinet was left unlock for hours accessible to cleints in care, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/14/2025
Plan of Correction
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Facility to submit LIC9098 self- certifying they will ensure Disinfectants, cleaning solutions, poisons, firearms and other items that could pose a danger if readily available to clients shall be stored where inaccessible to clients by POC due date
Type B
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
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Based on observation, the licensee did not comply with the section cited above in 2 out of 3 bathroom faucets measured between 128.1 and 136.2 degrees F, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/14/2025
Plan of Correction
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 Administrator agrees to keep a daily log of temperature for 1 week. Facility to send in written statement they understand regulation 80088(e)(1). by POC due date 11/14/2025 with log showing water temp is within regulation to clear citation.
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: 11/06/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/06/2025


LIC809 (FAS) - (06/04)
Page: 5 of 9
Document Has Been Signed on 11/10/2025 08:12 AM - It Cannot Be Edited


Created By: Shannan Hansen On 11/06/2025 at 03:36 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: NOVATO RESIDENTIAL SUPPORT SERVICES
FACILITY NUMBER: 210109022

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/06/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80077.3(a)(3)(C)
Care for Clients who Lack Hazard Awareness or Impluse Control
(C) Following the disaster and mass casualty plan specified in Section 80023, fire and earthquake drills shall be conducted at least once every three months on each shift and shall include, at a minimum, all facility staff who provide or supervise client care and supervision.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review and staff interview, the licensee did not comply with the section cited above as last disaster drill was contucted 3/14/2025 which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/14/2025
Plan of Correction
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Administrator to submit LIC9098 self certification of understanding of regulation and copy of new disaster drill conducted with date/signatures to clear POC.
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.
Bethany Moellers
NAME OF LICENSING PROGRAM MANAGER:
Shannan Hansen
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 11/06/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/06/2025


LIC809 (FAS) - (06/04)
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