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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 216803577
Report Date: 08/21/2025
Date Signed: 08/21/2025 12:49:23 PM

Document Has Been Signed on 08/21/2025 12:49 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: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:
08/21/2025
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:30 AM
MET WITH:Sheri Lott, AdministratorTIME VISIT/
INSPECTION COMPLETED:
01:00 PM
NARRATIVE
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Licensing Program Analyst (LPA) Hansen was at facility conducting complaint investigation and conduct a Case Management - Incident Visit and met with Administrator, Sheri Lott. The purpose of the visit was to follow up on self-reported incident that was submitted to Community Care Licensing (CCL).

CCL received an incident report on 8/13/2025. Report stated that on 8/11/2025, at approximately 8am staff (S1) accidentally administered medication to Client (C1) that was for another client. S1 contacted Administrator to report the error. The pharmacy was contacted regarding the error.

Per conversation with Administrator, staff monitored C1 for any changes. Was told by the pharmacist not to administer any medication to C1 for a 12 hour cycle. Medication for C1 were resumed at 8pm same day. S1 is in the process of being retrained for medication administration procedures. Facility made all appropriate notifications per regulation. (see LIC809D). Facility had medication error with same client, same situation 3/4/2025.

Additionally, when LPA arrived at facility (8/21/2025) at approximately 8:50am there was only 1 staff (S2) who was still there from the overnight shift (NOC) with 4 clients as 1 was at skilled nursing facility. LPA was informed other NOC shift staff left at approximately 8am. The morning shift staff did not arrive until approximately 9:15am. (see LIC809D)

Appeal Rights Given

The following deficiencies were observed (see LIC 9099D) 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. Copy of report, LIC809D, LIC 811 (Confidential Names), and Appeal Rights discussed and provided to Staff.

NAME OF LICENSING PROGRAM MANAGER: Bethany Moellers
NAME OF LICENSING PROGRAM ANALYST: Shannan Hansen
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 08/21/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/21/2025
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 08/21/2025 12:49 PM - It Cannot Be Edited


Created By: Shannan Hansen On 08/21/2025 at 11:54 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: WALDO HOUSE
FACILITY NUMBER: 216803577

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/21/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
08/22/2025
Section Cited
CCR
80075(b)(5)(B)

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80075(b)(5)(B) Health Related Services: (b) Clients shall be assisted as needed with self-administration of prescription & nonprescription medications. (5)..., providing all of the following requirements are met: (B) Once ordered by the physician the medication is given according to the physician's directions. This requirement was not met as evidenced by:
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Administrator informed S1 will not assist with medication administration until In-Service Training for S1 on Medication Administration Procedures is complete and submit proof of training conducted to CCL by POC due date 08/22/2025 to clear citation.

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Based on document review, Administrator did not comply with the section cited above as C1 was administered medication meant for another client. This poses an immediate health, safety and personal rights risk to clients in care.
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Type B
08/22/2025
Section Cited
CCR85065.5(a)(1)

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85065.5(a)(1) Staff-Client Ratio: Whenever a client who relies upon others to perform all activities of daily living is present, the following minimum staffing requirements shall be met; for Regional Center clients, staffing shall be maintained as specified by the Regional Center. This requirement is not
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Administrator to ensure facility maintains the required staffing ratio for clients. Administrator has been recruiting staff and will submit self-certification of understanding of regulation and Plan if there is not enough staff for a day. Administrator agrees to submity POC by 8/21/2025.
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as evidenced by: Based on a record review and observation, Faciltiy failed to ensure staffing ratios were met on 8/21/25 during site visit. This poses a potential Health, Safety or personal rights risk to clients.
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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: 08/21/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/21/2025


LIC809 (FAS) - (06/04)
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