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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 216800762
Report Date: 07/01/2025
Date Signed: 07/01/2025 04:01:00 PM

Document Has Been Signed on 07/01/2025 04:01 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 LAMONT HOUSEFACILITY NUMBER:
216800762
ADMINISTRATOR/
DIRECTOR:		RAMOS, IANFACILITY TYPE:
735
ADDRESS:816 LAMONT AVETELEPHONE:
(415) 892-1728
CITY:NOVATOSTATE: CAZIP CODE:
94945
CAPACITY: 6CENSUS: 6DATE:
07/01/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:30 AM
MET WITH:Ian Ramos, AdministratorTIME VISIT/
INSPECTION COMPLETED:
12:15 PM
NARRATIVE
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At approximately 8:30 AM, Licensing Program Analyst (LPA) Hansen arrived unannounced to conduct a Required 1 Year visit and met with House Manager, Ronald Berliner. Administrator, Ian Ramos, arrived later during visit at approximately 9:00AM. Facility is an Adult Residential Home that provides care and assistance for Adults with Disabilities. Facility has an approved fire clearance and capacity for 6 ambulatory clients. Upon arrival, LPA was informed that there were 6 clients in care, and all six clients were out of the community attending Day Program. Facility is a two-story building with 6 bedrooms, 3 bathrooms, two staff rooms, and common spaces.

At approximately 8:40 AM, LPA conducted a walk-though of the facility with Administrator & House Manager. LPA observed the following: The facility was found to be clean and at a comfortable temperature with all exits free from obstruction; although client room 1 was missing window screen and had strong pungent odor, bathroom 2 needs base of shower fixed and tub needs new grout or cleaned (see pic) & bathroom 3 needs electric air vent (no window) fixed as it is not working and has strong urine odor, and base of shower to be fixed/re grouted/replace top of base of shower where one walks in, is broken (see pics) and missing kitchen cabinet door to be replace (see LIC809-D). Facility had emergency lighting. There was a sufficient supply of both perishable and nonperishable foods as required by Title 22 Regulations. Toxins were observed to be stored inaccessible to clients; although seizors were observed in unlocked kitchen drawer and cleaning supplies bleach (see pics) were in bathroom cabinet under sink accessible to clients in care, and removed immediately by staff (see LIC809-D). There was an appropriate supply of cleaning products, linens, hygiene products and paper products available for clients. Mattress pads were in place or available for client use. Hot water temperatures for all sinks in facility were within Title 22 regulations of 105 to 120 degrees F.

At approximately 9:45AM, LPA reviewed the Facility's Staff Roster and found that all staff were background cleared and associated to facility per regulation. LPA reviewed 4 staff files, 5 of 6 client files, client medication, and client P&I monies.. All files were found to be well organized, thorough and contained the required documentation. Continued on LIC809C
NAME OF LICENSING PROGRAM MANAGER: Bethany Moellers
NAME OF LICENSING PROGRAM ANALYST: Shannan Hansen
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 07/01/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/01/2025
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 07/01/2025 04:01 PM - It Cannot Be Edited


Created By: Shannan Hansen On 07/01/2025 at 11:33 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: CEDARS LAMONT HOUSE
FACILITY NUMBER: 216800762

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/01/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
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 observation & interview, the licensee did not comply with the section cited above in [client room 1 was missing window screen and had strong pungent odor, bathroom 2 needs base of shower fixed and tub needs new grout or cleaned (see pic) & bathroom 3 needs electric air vent (no window) fixed as it is not working and has strong urine odor, and base of shower to be fixed/re grouted/replace top of base of shower where one walks in, is broken (see pics) and missing kitchen cabinet door to be replace, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/18/2025
Plan of Correction
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Administrator agrees to replace kitchen cabinet, fix both bathrooms (send pics & receipt of ventalation parts/work order), put window screen in client room 1, and signed/dated training log of staff who clean rooms. Submit to CCL/LPA Hansen by POC due date of 7/18/2025 to clear citation.
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 & interview, the licensee did not comply with the section cited above in finding seizors were observed in unlocked kitchen drawer and cleaning supplies bleach (see pics) were in bathroom cabinet under sink accessible to clients in care, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/18/2025
Plan of Correction
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Administrator to conduct staff training on keeping items that could pose a danger if readily available to client in care per regulation 80087(g). Submit training log with traininger,signatures, dates to CCL/LPA Hansen by POC due date of 7/18/2025 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: 07/01/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/01/2025


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: CEDARS LAMONT HOUSE
FACILITY NUMBER: 216800762
VISIT DATE: 07/01/2025
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Continued from LIC809

Client files had updated Individual Program Plans/Individual Service Plans. Staff files had current First Aid and CPR certification. P&I monies were documented, secure and not commingled. Administrator's Certificate for Ian Ramos (7002761735) expiration date of 10/18/2025.

Fire extinguishers were last inspected February 6, 2024. Smoke detectors and carbon monoxide detectors were tested and operational. Facility conducts emergency disaster drill’s monthly with the last conducted 6/6/2025. Facility has emergency generator should power go out.




LPA requested the following documents to update facility file:
· Designation of Facility Responsibility (LIC 308)
· Emergency Disaster Plan (LIC 610D) (if changes)
· Updated Personnel Report (LIC 500)
· Surety Bond (LIC 402)
· Register of Clients (LIC 9020)
· Current Administrator Certificate

Documents to be submitted to Community Care Licensing (CCL) by due date of 7/18/2025.

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. Copy of report discussed and provided to House Manager and Administrator. Signature on form confirms receipt of documents.
NAME OF LICENSING PROGRAM MANAGER: Bethany Moellers
NAME OF LICENSING PROGRAM ANALYST: Shannan Hansen
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 07/01/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/01/2025
LIC809 (FAS) - (06/04)
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