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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 216803577
Report Date: 10/09/2025
Date Signed: 10/10/2025 09:43:19 AM

Document Has Been Signed on 10/10/2025 09:43 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:WALDO HOUSEFACILITY NUMBER:
216803577
ADMINISTRATOR/
DIRECTOR:		LOTT, SHERIFACILITY TYPE:
735
ADDRESS:55 WALDO COURTTELEPHONE:
(415) 271-3304
CITY:SAUSALITOSTATE: CAZIP CODE:
94965
CAPACITY: 5CENSUS: 5DATE:
10/09/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:45 AM
MET WITH:Sheri Lott, AdministratorTIME VISIT/
INSPECTION COMPLETED:
03:15 PM
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Licensing Program Analyst (LPA) Shannan Hansen arrived unannounced to conduct an Annual inspection of facility and was welcomed by staff Yardly (NOC) and Lanisa who contacted House Manger and Administrator who arrived during visit. Facility is a 2 story building with all 5 bedrooms, three bathrooms, & communal areas on top floor that is adjacent to driveway. Bottom floor is office space, bathroom, kitchenette, overflow food & storage room, and garage. Facility granted fire clearance by Marin County Fire Department for 5 client bedrooms 1 of which may be Non-ambulatory. During today’s inspection facility has 5 clients although one is still at skilled nursing facility from injury.

LPA and staff initiated a tour of the facility at approximately 8:55am and made the following observations: Facility was a comfortable temperature and passageways were free from obstructions. Client rooms were furnished per regulation; although House Manager informed C1 does not have a chair as they use it as a weapon. Water temperature in sinks accessible to clients measured at 115 and 118.5 degrees F within regulations of 105 to 120 degrees F in 2 of 2 client bathrooms tested. Extra hygiene products and linens were available. Cleaning supplies and disinfectants are stored in upstairs closet next to washer & dryer that at approximately 9:10am on 10/9/2025 was observed to be unlocked containing; comet w/ bleach, Easy Off Heavy duty oven cleaner, 2- 64 oz kingsford charcoal lighter fluid, large container of Clorox cleaner + bleach, and gallon of cloralen bleach “High performance bleach for commercial use/home use and other cleaning supplies (see pics & LIC 809-D). Also observed by staff & LPA in downstairs garage overflow storage closet (with sign this door to remain locked at all times) hand lock does not always lock, contained 2 five gallon buckets of paint and smaller paint cans, cabinets with signage for additional cleaning supplies, additional freezers and food and emergency food supplies, which are not to be stored in same space (see pics & LIC 809-D) toxins moved to locked storage shed prior to end of visit.). Continue on LIC809C
NAME OF LICENSING PROGRAM MANAGER: Bethany Moellers
NAME OF LICENSING PROGRAM ANALYST: Shannan Hansen
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 10/09/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/09/2025
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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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: WALDO HOUSE
FACILITY NUMBER: 216803577
VISIT DATE: 10/09/2025
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Continue from LIC809
Also observed from previous visit kitchen tile counter tops still not fixed (facility put duck tape over) & downstairs bathroom was to be fixed but still has not (see pics & LIC 809-D) not in good repair. Facility has at least two days of perishable and one week of non-perishable foods. Medications were centrally stored and locked. Emergency food, two freezers and water supplies are stored in the garage overflow with toxins (see pics & LIC809-D) although by end of visit toxins were removed and place in secured storage shed.

At approximately 11:15pm LPA conducted review of five client files and five staff files. LPA reviewed client’s files and learned that 5 out of 5 clients records found to be current for care plan/IPP/ISP; although 1 out of 5 clients did not have a Physician Assessments (see LIC-809D).

LPA reviewed a sample of staff records at 12:45 PM and learned that all facility staff present and a sample of other individuals who require caregiver background checks have received criminal record clearances or exemptions. Direct care staff annual training requirements for 2024/2025 and are on file. LPA was presented with proof of CPR & 1st Aid certification for staff that files were reviewed on 10/9/2025. Medications and medication records and client cash resources were also reviewed. LPA observed missed medications due to medication not being refilled.

Fire extinguisher was last serviced on 8/29/2025. Facility has Smoke and Carbon Monoxide detectors located throughout the facility that were tested and operational during visit. Most recent fire/disaster drill was conducted in 9/26/2025 and are conducted at least quarterly and in different shifts. Administrator Certificate for Administrator Sheri Lott 7008747735 expires 11/17/2025.

Appeal 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.
Licensee/Administrator to submit updates of the following documents by 10/30/2025:

LIC 308 Designation of Facility Responsibility
LIC 400 Affidavit Regarding Client Cash Resources
LIC 500 Personnel Report


LIC 610 Emergency Disaster Plan (If changes)
LIC9020 Register of Facility Client’s
Submit either Updated Lease Agreement or Control of Property (Deed)
NAME OF LICENSING PROGRAM MANAGER: Bethany Moellers
NAME OF LICENSING PROGRAM ANALYST: Shannan Hansen
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 10/09/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/09/2025
LIC809 (FAS) - (06/04)
Page: 6 of 6
Document Has Been Signed on 10/10/2025 09:43 AM - It Cannot Be Edited


Created By: Shannan Hansen On 10/09/2025 at 02:06 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: WALDO HOUSE
FACILITY NUMBER: 216803577

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/09/2025

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 LPA & staff observations, the licensee did not comply with the section cited above in observing Cleaning supplies and disinfectants stored in upstairs closet next to washer & dryer that at approximately 9:10am on 10/9/2025 was observed to be unlocked containing; comet w/ bleach, Easy Off Heavy duty oven cleaner, 2- 64 ox kingsford charcoal lighter fluid, large container of Clorox cleaner + bleach, and gallon of cloralen bleach “High performance bleach for commercial use/home use and other cleaning supplies which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 10/10/2025
Plan of Correction
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Licensee will secure all cleaning solutions and poisons in the facility. Administrator to submit self certificaiton by POC 1st POC due date of 10/10/25 indicating understanding of regulations. Administrator to submit proof of training to all staff regarding regulation with dates/signatures/ Title of training by POC due date of 10/16/2025.
Type A
Section Cited
CCR
80087(i)
Building and Grounds
(i) The items specified in Section 80087(g) above shall not be stored in food storage areas or in storage areas used by or for clients.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA's & Administration observation, the licensee did not comply with the section cited above in findings toxins & cleaning supplies in emergency/overflow food storage closet which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 10/09/2025
Plan of Correction
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Administrator removed paint and cleaning supplies and moved to outside secured Hut/storage. POC cleared during visit.
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: 10/09/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/09/2025


LIC809 (FAS) - (06/04)
Page: 3 of 6
Document Has Been Signed on 10/10/2025 09:43 AM - It Cannot Be Edited


Created By: Shannan Hansen On 10/09/2025 at 02:06 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: WALDO HOUSE
FACILITY NUMBER: 216803577

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/09/2025

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 LPA's & staff observation , the licensee did not comply with the section cited above in observing from previous visit kitchen tile countertops still not fixed (facility put duck tape over) & downstairs bathroom was to have new drywall covering but still has not which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/07/2025
Plan of Correction
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Administrator had scheduled 2 different contractors to fix both issues but did not fix it yet. Administrator will contact tomorrow and whill have kitchen tile countertops and drywall in downstairs bathroom fixed and send proof to CCL/LPA by POC due date of 11/7/2025
Type B
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 LPA's & Administrator observation, the licensee did not comply with the section cited above in finding metal rakes, metal shovels in backyard accessible to client which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/17/2025
Plan of Correction
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Licensee/Administrator to ensure all items that could pose a danger remain inaccessible to clients AT ALL TIMES. Licensee to submit a LIC 9098 self certification that all staff in the facility understands Title 22 Regulation 80087(g), and that all items that could pose danger to clients are inaccessible to CCL by POC date of 10/17/2025.
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: 10/09/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/09/2025


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 10/10/2025 09:43 AM - It Cannot Be Edited


Created By: Shannan Hansen On 10/09/2025 at 02:36 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: WALDO HOUSE
FACILITY NUMBER: 216803577

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/09/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80069(b)
80069 Client Medical Assessment - (b) In ARFs , prior to accepting a client into care, the licensee shall obtain and keep on file documentation of the client's medical assessment.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review and interviews, licensee did not comply with the regulation above in 1 of 5 clients, due to accepting clients without obtaining a medical assessment per reg. This is a potential health, safety, and personal rights risk to clients in care.
POC Due Date: 10/20/2025
Plan of Correction
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Licensee/Administrator to submit complete LIC602 for clients C1 to community care licensing. Administrator indicated C1's health insurance had not transfered and was not able to schedule doctors appointment. POC due by 10/20/2025
Section Cited
Deficient Practice Statement
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3
4
POC Due Date:
Plan of Correction
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4
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: 10/09/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/09/2025


LIC809 (FAS) - (06/04)
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