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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 216801291
Report Date: 12/09/2025
Date Signed: 12/09/2025 03:18:13 PM

Document Has Been Signed on 12/09/2025 03:18 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 FERRIS DRIVEFACILITY NUMBER:
216801291
ADMINISTRATOR/
DIRECTOR:		KEMMETER, FRANKFACILITY TYPE:
735
ADDRESS:1106 FERRIS DR.TELEPHONE:
(415) 892-1208
CITY:NOVATOSTATE: CAZIP CODE:
94945
CAPACITY: 6CENSUS: 6DATE:
12/09/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:45 AM
MET WITH:Bryan Zafra Gonzalez, House ManagerTIME VISIT/
INSPECTION COMPLETED:
02:30 PM
NARRATIVE
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On 12/09/2025, Licensing Program Analyst (LPA) Hansen arrived unannounced to conduct an Annual inspection of this facility. LPA was greeted by staff Vivian who contacted House Manager Brayan Gonzalez who arrived shortly after. Upon arrival there were 2 clients waiting to be taken to a day program and outing with their 1 on 1, the other 4 clients had already been taken to day programs. Facility is single story with 6 client bedrooms and 2 client bathrooms. Novato Fire Dept has approved for 6 ambulatory residents of which 1 may be non-ambulatory.

At approximately 9:00am, LPA and staff began tour of building and grounds, House Manager joined shortly after. The facility was found to be at a comfortable temperature. LPA observed a 2 day supply of perishable and 7 day supply of non-perishable food. Refrigerated food was found to be stored in a safe manner.

All rooms were equipped with lighting, night stand, and chest of drawers. All rooms were in good repair. Extra hygiene products and linens were available. Water temperature in sinks accessible to clients in care were measured at 125.6 degrees F and 125.9 degrees F, not within Title 22 regulations of 105 to 120 degrees F (see LIC809D). Shower head in bathroom has needed to be repaired/replaced for over a week (per staff) and clients have been using other bathroom, as well kitchen cabinet to the lower left of kitchen sink is broken (see LIC809D). Fire extinguishers were last inspected 02/19/2025. Smoke/Carbon Monoxide detectors located throughout the facility were tested and operational. Toxins are stored in a locked cabinet inside the garage, however; LPA observed Clorox and Ajax unlocked under sink of 2 different unlocked bathrooms and a kitchen cabinet unlocked with several toxins as well, knife/scissor/sharp drawer also left unlocked accessible to residents in care (see LIC 809-D, see pictures). LPA conducted spot medication count and found all prescription medication to be properly recorded on the Centrally Stored Medication Record. P & I monies were documented. Facility conducts monthly fire and disaster drills with the last being 11/12/2025.

Continue on LIC809C

NAME OF LICENSING PROGRAM MANAGER: Bethany Moellers
NAME OF LICENSING PROGRAM ANALYST: Shannan Hansen
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 12/09/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/09/2025
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 7
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 12/09/2025 03:18 PM - It Cannot Be Edited


Created By: Shannan Hansen On 12/09/2025 at 01:45 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: CEDARS FERRIS DRIVE
FACILITY NUMBER: 216801291

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/09/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
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 observation and interview, the licensee did not comply with the section cited above several unlocked toxins which poses an immediate health, safety or personal rights risk to persons in care. LPA observed dishwasher & dish cleaning supplies with clorox under an unlocked cabinet sink and several toxins in an unlocked kitchen cabinet. (see pictures)
POC Due Date: 12/10/2025
Plan of Correction
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Licensee agrees to ensure that all toxins and other items that could pose danger to clients in care will be locked at all times. Facility to lock all toxins and submit a self certification to CCL by POC date by 12/10/2025. Also submit (sign & dated) training log for all staff regarding regulations by 2nd POC due date of 12/19/2025 to clear citation.
Type A
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 2 bathroom faucets which poses an immediate health, safety or personal rights risk to persons in care. Facility hot water temperature in clients' bathroom faucets measured between 125.6 degrees F and 125.9 degrees F.
POC Due Date: 12/10/2025
Plan of Correction
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Licensee agrees to ensure that hot water temperature on client's faucets will maintain temperatures between 105 degrees F and no more than 120 degrees F. Facility to adjust hot water temperature and submit a self certification that water has been adjusted to CCL by 12/10/2025. In addition, facility to submit a 7 day hot water temperature log by 12/19/2025 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: 12/09/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/09/2025


LIC809 (FAS) - (06/04)
Page: 3 of 7
Document Has Been Signed on 12/09/2025 03:18 PM - It Cannot Be Edited


Created By: Shannan Hansen On 12/09/2025 at 01:45 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: CEDARS FERRIS DRIVE
FACILITY NUMBER: 216801291

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/09/2025

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 , the licensee did not comply with the section cited above in observing shower head in mens bathroom to be broken (per staff all clients using 1 shower for over a week) & kitchen cabinet drawer needs fixing which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/19/2025
Plan of Correction
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Licensee to fix shower head and kitchen cabinet door, submit receipt or work order that they have been fixed with statement, submit to LPA by POC due date 12/19/2025 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: 12/09/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/09/2025


LIC809 (FAS) - (06/04)
Page: 4 of 7
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 FERRIS DRIVE
FACILITY NUMBER: 216801291
VISIT DATE: 12/09/2025
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Continued from LIC809

LPA conducted a review of 5 client records. All records had the required documentation. LPA conducted review of 5 staff records/training. Upon a review of staff records, LPA found all staff to have required annual and initial training as well as current 1st Aid & CPR certification on file.

Administrator certificate for Frank Kemmeter 7013655735 exp 06/27/2027.

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.

Updated copies of the following documents were requested for facility file and are to be submitted to CCL by 01/14/2026:

LIC500- Personnel Report

LIC308- Designation of Responsibility

LIC400- Affidavit Regarding Client Cash Resources

LIC9020 – Client Roster

Exit interview conducted with House Manager and a copy of this report was provided.

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

DATE: 12/09/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/09/2025
LIC809 (FAS) - (06/04)
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