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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 216800881
Report Date: 06/19/2025
Date Signed: 06/20/2025 07:19:09 AM

Document Has Been Signed on 06/20/2025 07:19 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:SAN LUIS HOUSEFACILITY NUMBER:
216800881
ADMINISTRATOR/
DIRECTOR:		KAYLA HOTCHKISSFACILITY TYPE:
735
ADDRESS:396 SAN LUIS WAYTELEPHONE:
(415) 525-1082
CITY:NOVATOSTATE: CAZIP CODE:
94945
CAPACITY: 6CENSUS: 6DATE:
06/19/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:50 AM
MET WITH:Kayla Hotchkiss, Administrator & Nakia Bibbs, Program ManagerTIME VISIT/
INSPECTION COMPLETED:
03:15 PM
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Licensing Program Analyst (LPA) Hansen arrived unannounced to conduct annual inspection of facility and was welcome by staff Veronica Samuel. Administrator Kayla Hotchkiss was contacted by telephone and arrived during visit. The facility is a single story five-bedroom, two bathrooms with a fire clearance for 6 Ambulatory clients. Clients were at the facility as it was a holiday but left shortly after to another community house to shower as new water heater has malfunctioning part, repair company is waiting on. There are 6 clients at the facility.

LPA toured the facility on 6/19/2025 at 9:30 AM with Staff Veronica Samuel; facility was found to be clean and at a comfortable temperature with all exits free from obstruction. Gate in kitchen adjacent to back sliding glass door exit has been removed. Fire Extinguisher was found to be last charged on 5/1/2025 at the time of the visit. Smoke detectors were found to be operational along with carbon monoxide detector. Hot water temperature measured 91.9 degrees F not within Title 22 acceptable regulation of 105 to 120 degrees F in 2 of 2 client’s bathrooms while touring facility on 6/19/2025 (see LIC809-D). LPA was informed water heater was replaced approximately 3 weeks ago, on 6/14/2025 hot water heater stopped working, repair/replacement company was called and came out on 6/16/2025 identifying a part malfunctioned and replacement has been ordered. At end of annual LPA was informed replacement part just arrived, and repair/plumbing company will be out 6/20/2025 at 10am. Facility’s clients are showering at sister community house during this time. Dishes are being washed with heated water from stove & microwave. 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 and cleaning supplies are stored in locked cabinet inside the laundry/garage. Dangerous items were stored inaccessible to develop disabled clients.
Continue on LIC 809-C
NAME OF LICENSING PROGRAM MANAGER: Bethany Moellers
NAME OF LICENSING PROGRAM ANALYST: Shannan Hansen
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 06/19/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/19/2025
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 06/20/2025 07:19 AM - It Cannot Be Edited


Created By: Shannan Hansen On 06/19/2025 at 02:25 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: SAN LUIS HOUSE
FACILITY NUMBER: 216800881

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/19/2025

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 observation and interview with Administrator, the licensee did not comply with the section cited above in observing 2 bedroom window screens missing along with screen door and 2 other window screens needing repairs which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/27/2025
Plan of Correction
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Licensee to replace & fix window screens and submit pictures with statement to LPA Hansen by POC due date of 6/27/2025 to clear citation.
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 LPA's observation and Interview with Administrator, the licensee did not comply with the section cited above in 2 out of 2 residents bathrooms only reached 91.1 degrees F which poses/posed a potential health, safety or personal rights risk to persons in care. Administrator explained they are getting new hot water heater fixed as there was a faulty part.
POC Due Date: 06/27/2025
Plan of Correction
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Licensee to submit proof of correction with one weeks water log and pluming receipt that hot water heater has been fixed to LPA Hansen by POC due date 6/27/2025 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: 06/19/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/19/2025


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 06/20/2025 07:19 AM - It Cannot Be Edited


Created By: Shannan Hansen On 06/19/2025 at 02:25 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: SAN LUIS HOUSE
FACILITY NUMBER: 216800881

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/19/2025

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 and interview with Administrator and S1, the licensee did not comply with the section cited above in 1 out of 5 staff records reviewed did not have a current 1st Aid certification which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/27/2025
Plan of Correction
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Licensee to submit S1's current First Aid certificaiton to LPA Hansen by POC due date 6/27/2025 to clear citation.
Type B
Section Cited
HSC
1565(c)
Other Provisions
(c) A facility shall conduct a drill at least quarterly for each shift. The type of emergency covered in a drill shall vary from quarter to quarter, taking into account different emergency scenarios. An actual evacuation of individuals served by the facility is not required during a drill. While a facility may provide an opportunity for individuals served by the facility to participate in a drill, it shall not require that participation. Documentation of the drills shall include the date, the type of emergency covered by the drill, and, if applicable, the names of staff participating in the drill.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA's record review & interview with Administrator, the licensee did not comply with the section cited above in not being able to provide proof of disaster drills, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/27/2025
Plan of Correction
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Licensee to conduct Disaster Drill with all staff and provide drill with date/signatures of all staff/type of drill to LPA Hansen by POC due date of 6/27/2025 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: 06/19/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/19/2025


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: SAN LUIS HOUSE
FACILITY NUMBER: 216800881
VISIT DATE: 06/19/2025
NARRATIVE
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Continue 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 six client’s bedrooms have lighting & appropriate furnishings, and all beds were outfitted with mattress pads for clients as per Title 22 regulations. During tour of facility grounds LPA & Program Manager observed 2 missing bedroom window screens and (2 needing repairs) along with back sliding glass door not having a screen and being open (see LIC809-D).

A review of six clients files and two client’s medications was conducted at the facility. LPA reviewed client’s files at approximately 11:00 AM and learned that 5 of 5 clients have an updated Individual Service Plan/Individual Program Plan, and physician’s report on file at this time as required by Title 22 Regulation. Personal Rights for 6 of 6 clients were signed and on file. P&I's are kept in a locked filed cabinet in the facility office room; facility responsible for all client’s P&I and money; facility had P& I and ledgers available during the visit. P& I money not comingle and ledgers are current at this time. LPA reviewed a sample of staff records at 1:00 PM on 6/19/2025 and learned that all facility staff present and other individuals who require caregiver background checks have received criminal record clearances or exemptions. In addition, Direct care staff at the facility have received the additional training requirements. LPA was presented with proof of 1st Aid certification for staff that files were reviewed; other then S1 who did not have required certification (see LIC809-D).

Medications were centrally stored in a locked cabinet in the facility office. LPA conducted a review of medications for two clients. The Medications of 1 of 2 clients were found to be given according to physicians’ directions. Centrally Stored Medication Records (CSMR) on 6/19/2025 were not accurate for 1 of 2 clients in the facility, finding C1 had 4 evening/bedtime medications missing/unaccounted/undocumented for (see LIC9102TV). Administrator informed C1 went home for visit and returned with 1 evening of medications, not logged and could not find additional.
Administrator, Kayla Hotchkiss Certificate # 7032017735 expires 12/6/2025. Administrator informed LPA documents to change Administrator were sent to CCL 9/2024 but has not been changed, will be resubmitting to current LPA to change. Last recording of a Disaster drills was 12/3/2023, Administrator informed facility was painted approximately 1 month ago and logs have been misplaced (see LIC809-D).
Continue on LIC809-C2
NAME OF LICENSING PROGRAM MANAGER: Bethany Moellers
NAME OF LICENSING PROGRAM ANALYST: Shannan Hansen
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 06/19/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/19/2025
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: SAN LUIS HOUSE
FACILITY NUMBER: 216800881
VISIT DATE: 06/19/2025
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Continued from LIC809-C

Facility built office in garage 5/2022 without fire clearance and at recent inspection observed gate between kitchen and office/medication/room etc. that is adjacent to exit, has now been removed. CCL has requested fire clearance.

Deficiencies 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. Appeal Rights given.

LPA is requesting the following updated documents be submitted to CCL by 7/1/2023:


LIC 308 Designated


LIC 500 Personnel Summary
LIC 400 Affidavit Regarding Resident Cash Resources
LIC 402 Surety Bond
LIC 610 Emergency Disaster Plan
LIC 9020 Register of Facility Client’s/Resident’s
Copy of Administrator Certificate
NAME OF LICENSING PROGRAM MANAGER: Bethany Moellers
NAME OF LICENSING PROGRAM ANALYST: Shannan Hansen
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 06/19/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/19/2025
LIC809 (FAS) - (06/04)
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