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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 216801723
Report Date: 07/10/2025
Date Signed: 07/10/2025 05:16:59 PM

Document Has Been Signed on 07/10/2025 05:16 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:BEACON HILLFACILITY NUMBER:
216801723
ADMINISTRATOR/
DIRECTOR:		BENOIT, WILSONFACILITY TYPE:
735
ADDRESS:826 HAYDEN AVE.TELEPHONE:
(415) 897-9716
CITY:NOVATOSTATE: CAZIP CODE:
94945
CAPACITY: 6CENSUS: 4DATE:
07/10/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:15 AM
MET WITH:Licensee, Walvelt Hyppolite & Administrator Wilson BenoitTIME VISIT/
INSPECTION COMPLETED:
01:00 PM
NARRATIVE
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Licensing Program Analyst (LPA) Shannan Hansen arrived unannounced at approximately 8:15 AM to conduct an Annual Required inspection and was greeted by staff Marie B. who contacted Administrator, Wilson Benoit and Licensee, Wally Hyppolite who arrived shortly after. This tri-level Adult Residential Facility has 6 bedrooms, 2 bathrooms, dining room, living room, kitchen, & recreation room that has a fire clearance approved for 6 Ambulatory clients. Facility has 4 clients, two are currently away at family homes, during inspection there was only 2 at facility and 1 left to day program shortly after LPA arrived, the other was sleeping per Licensee.

LPA and Licensee initiated a tour of the facility at approximately 8:45 AM and made the following observations: Facility was a comfortable temperature and passageways were free from obstructions. Resident rooms were furnished per regulation. Water temperature in sinks accessible to clients measured at 120.7 and 122.3 degrees F not within the range of 105 to 120 degrees F allowed per regulation (see LI809-D). Bathroom on 2nd level was observed to have a bottle of bleach under sink in unlocked cabinet and other empty containers (see pics & LIC809-D).

LPA observed the kitchen to be newly remodeled and in functioning condition. LPA observed cabinet under sink to be locked and contained various cleaning chemicals. Emergency food and water is stored in room outside of kitchen. Upon entering the backyard. LPA and Licensee observed numerous paint cans outside due to various projects that had been done and lock on side yard storage containing painting solvent and additional cans/buckets of paint not having working lock (see pics & LIC809-D).
Continue on LIC809-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)
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 07/10/2025 05:17 PM - It Cannot Be Edited


Created By: Shannan Hansen On 07/10/2025 at 12:00 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: BEACON HILL
FACILITY NUMBER: 216801723

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/10/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
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 observation & interview, the licensee did not comply with the section cited above in Bathroom on level 2 had bleach under sink in unlocked cabinet, numerous paint cans outside due to various projects that had been done and lock on side yard storage containing painters’ solvent and additional cans/buckets of paint not able to lock, bleach found in C1's room, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 07/11/2025
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 A
Section Cited
CCR
80075(k)(1)
Health-Related Services
(k) The following requirements shall apply to medications which are centrally stored: (1) Medication shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA & Licensee's observation, interview, and C1's record review that indicates client is unable to store own medications, the licensee did not comply with the section cited above in having prescription medication(cetirizine 10mg and other over the counter medications (DayQuil, B-Complete, Flaxseed, etc) in their room (see pics). which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 07/11/2025
Plan of Correction
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Licensee immediately removed medication bottle and other OTC supliments and locked them away in staff room. Licensee to keep all medications locked away at all times to ensure health and safety of clients. Licensee will review and train staff on the procedures in section 80075(k)(1). Licensee to submit understandin of regulation by 7/11/2025 and submit documentation of training to CCL by 7/18/2025.
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: 07/10/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/10/2025


LIC809 (FAS) - (06/04)
Page: 3 of 7
Document Has Been Signed on 07/10/2025 05:17 PM - It Cannot Be Edited


Created By: Shannan Hansen On 07/10/2025 at 12:00 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: BEACON HILL
FACILITY NUMBER: 216801723

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/10/2025

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 (see pics) the licensee did not comply with the section cited above in observing numberous empty bottles and trash in bags in recreation room, pourch, and back yard, along with linen closet containing dirt etc at bottom of closet, 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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Licensee/Administrator agrees to clean up garbage & debre, and linin closet(send pics) Sign and date self certification facility will remain clean of debre and garbage per regulation. Submit to CCL/LPA Hansen by POC due date of 7/18/2025 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 observation, the licensee did not comply with the section cited above in 2 out of 2 clients bathrooms measured water temperaturs of 120.7 degrees F & 122.3 degrees F out of regulation range, 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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LIcensee to turn water heater down and keep 5 day log of water tempterature in both client bathrooms and submit to CCL by POC due date 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: 07/10/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/10/2025


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: BEACON HILL
FACILITY NUMBER: 216801723
VISIT DATE: 07/10/2025
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Continued from LIC809:
Extra hygiene products and linens were available although closet containing linens at the bottom had dirt/empty containers & debris that needed to be cleaned up. During tour LPA, Licensee, & Administrator observed empty cans, containers, & bottles needing to be removed and taken away. Facility has at least two days of perishable and one week of non-perishable foods which were of quality and stored per regulation. Medications were centrally stored and locked; although at approximately 9:00am while touring client (C1) bedroom # 5, LPA and Licensee observed prescription medication and other over the counter medications (DayQuil, B-Complete, Flaxseed, etc.)(see pics & LIC809-D) Licensee informed C1 does not have a Dr.’s note authorizing the ability to retain medications. Also a spray bottle of Clorox cleaner + bleach was observed in C1’s room, Licensee removed all medications and cleaning chemicals.

Fire extinguishers were last serviced May 14, 2025. Facility smoke and carbon monoxide detectors located throughout the facility were tested and operational during inspection. Facility conducts quarterly disaster drills with the most recent fire/disaster drill was conducted 6/9/2025. Client cash resources were reviewed. Facility currently only handles one clients cash resources. Remaining clients handle their own cash.

Four staff files and four client files were reviewed. All but 1 staff (S1) have required First Aid and CPR certificates (see LIC9102 TV). Medications and medication records were reviewed. Administrator Certificate for Wilson Benoit # 7001725735 expires 01/31/2027.
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

Exit interview conducted. Copy of report discussed and provided to Administrator. Signature on forms confirms receipt of documents.
LPA is requesting the following documents to be submitted to Community Care Licensing by 07/31/2025:
LIC 400 Client Cash Resources


LIC 402 Surety Bond
LIC 500 Personnel Report
LIC 9020 Client Roster
LIC 308 Designation of facility responsibility
NAME OF LICENSING PROGRAM MANAGER: Bethany Moellers
NAME OF LICENSING PROGRAM ANALYST: Shannan Hansen
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 07/10/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/10/2025
LIC809 (FAS) - (06/04)
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