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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 210109022
Report Date: 11/12/2025
Date Signed: 11/12/2025 02:58:21 PM

Document Has Been Signed on 11/12/2025 02:58 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: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:
11/12/2025
TYPE OF VISIT:Case Management - Annual ContinuationUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:30 AM
MET WITH:John Ahrens, Program DirectorTIME VISIT/
INSPECTION COMPLETED:
12:50 PM
NARRATIVE
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11/12/2025 at approximately 8:30am, Licensing Program Analyst (LPA) Hansen arrived unannounced to continue an Annual Required inspection that was initiated on 11/06/2025, and was greeted by Luz Maldonado, Mental Health Counselor/staff. Program Director, John Ahrens and Assistant Program Director, Suhay Rivas arrived during visit.

LPA conducted a sample review of staff records at approximately 10:00 AM and learned that all staff present at the facility and other individuals who require caregiver background checks have received criminal record clearances or exemptions. Facility has proof of Direct care staff training for 2025. Facility was unable to provide proof of CPR & 1st Aid certification for 4 of 5 staff (S1,S2, S3, S4) records that were reviewed (see LIC809D).

LPA conducted a review of medications for two clients. The Medications of 2 of 2 clients were found to be given according to physicians’ directions at 10:30 AM.



Facility is being cited today for deficiencies from initial inspection (11/06/2025) regarding Client updated care plans (see LIC809D).

Assistant Program Director will be submitting LIC200 for updated facility email and mobile contact #.

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.

Continue on LIC809C
NAME OF LICENSING PROGRAM MANAGER: Bethany Moellers
NAME OF LICENSING PROGRAM ANALYST: Shannan Hansen
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 11/12/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/12/2025
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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Document Has Been Signed on 11/12/2025 02:58 PM - It Cannot Be Edited


Created By: Shannan Hansen On 11/12/2025 at 11:09 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: 11/12/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80068.3

80068.3 Modifications to Needs and Services Plan:(a) The licensee shall ensure that each client's written Needs and Services Plan is updated as often as necessary to assure its accuracy, but at least annually..


This requirement is not met as evidenced by:
Deficient Practice Statement
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these modifications shall be maintained in the client's file. Based on records reviewed, C1's service plan has not been updated since 2016. This poses a potential Safety risk.
POC Due Date: 11/14/2025
Plan of Correction
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Licensee/Administrator to ensure clients service plan is updated as needed to address new behaviors. Licensee/Administrator to update C1's plan and submit along with plan of how facility will maintain compliance with accuracy/time frame going foward self certification to CCL by POC date of 11/14/2025.
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: 11/12/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/12/2025


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 11/12/2025 02:58 PM - It Cannot Be Edited


Created By: Shannan Hansen On 11/12/2025 at 12:06 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: 11/12/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80075(f)
Health-Related Services
(f) Staff responsible for providing direct care and supervision shall receive training in first aid from persons qualified by agencies including but not limited to the American Red Cross.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review & interview with Assistant Program Director, the licensee did not comply with the section cited above in 4 out of 5 staff did not have proof of current First Aid certification which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/26/2025
Plan of Correction
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Licensee will submit current 1st Aid certificates (CPR) for 4 staff by 11/26/2025 to clear citation.
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: 11/12/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/12/2025


LIC809 (FAS) - (06/04)
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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: 11/12/2025
NARRATIVE
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Continued from LIC809

LPA Hansen is requesting Licensee/Program Director/Asst Program Director to update the following documents and submit to CCL by 11/25/2025:

LIC 308 Designated
LIC 500 Personnel Summary
LIC 610 Emergency Disaster Plan
LIC 9020 Register of Facility Client’s
Copy of updated Deed
Copy of Current Administrator's Certificate
NAME OF LICENSING PROGRAM MANAGER: Bethany Moellers
NAME OF LICENSING PROGRAM ANALYST: Shannan Hansen
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 11/12/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/12/2025
LIC809 (FAS) - (06/04)
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