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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 216803663
Report Date: 07/10/2026
Date Signed: 07/10/2026 01:36:05 PM

Document Has Been Signed on 07/10/2026 01:36 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
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME:GARDEN HOMEFACILITY NUMBER:
216803663
ADMINISTRATOR/
DIRECTOR:		ZHU, XIAOTONG "SHERRY"FACILITY TYPE:
740
ADDRESS:16 GARDEN AVETELEPHONE:
(415) 350-6636
CITY:SAN RAFAELSTATE: CAZIP CODE:
94903
CAPACITY: 4CENSUS: 4DATE:
07/10/2026
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:30 AM
MET WITH:Staff Members, Elsa Bacsal and Lisa Lin, and Administrator, Tom YuanTIME VISIT/
INSPECTION COMPLETED:
01:45 PM
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At approximately 8:30AM, Licensing Program Analyst (LPA) Felias arrived unannounced to conduct a 1 Year Required visit and met with Staff Members, Elsa Bacsal and Mary Wang. Administrator, Tom Yuan, arrived during visit at approximately 9:00AM. Licensee, Sherry Zhu, arrived during visit at approximately 9:20AM. Facility is a Residential Home for the Elderly that provides care and assistance for Older Adults with Disabilities. Facility has an approved fire clearance and capacity for 4 Non-Ambulatory Residents. Facility has a hospice waiver for 1 individual. Upon arrival, LPA was informed that there were 4 residents in care, with 2 residents preparing to leave for their Day Program. LPA was also informed that there were 2 staff members on site.

At approximately 8:45AM, LPA reviewed the Facility's Staff Roster and found that all staff on site were background cleared and associated to the facility per regulation. LPA conducted a walk-though of the facility with Administrator. LPA observed the following: Facility was found to be clean and at a comfortable temperature with all exits free from obstruction. Facility had emergency lighting. Facility is a one story building with 4 resident bedrooms, 2 bathrooms, and common spaces. Facility has an Infection Control plan on file. There was a sufficient supply of both perishable and nonperishable foods as required by Title 22 Regulations. There was an appropriate supply of cleaning products, linens, hygiene products and paper products available for residents. Mattress pads were in place or available for resident use. Toxins were observed to be stored inaccessible to residents. Hot water temperatures for all sinks in facility were within Title 22 regulations of 105 to 120 degrees Fahrenheit. During walkthrough, LPA observed that facility had multiple instances of expired foods in facility fridge and freezer including tofu and Costco prepared meals. LPA, Administrator, Licensee discussed checking foods to ensure that food stays safe for consumption. Administrator's Certificate for Tom Yuan (7003584740) was current with an expiration date of 05/19/2026.

Fire extinguishers were last inspected June 2026. Smoke detectors and carbon monoxide detectors were tested and operational. Facility's last emergency/disaster drill was conducted July 2026. Facility's emergency disaster plan was last reviewed and updated May 2025 and infection control plan were last reviewed and updated June 2025. Facility did not have
Continued LIC809C
NAME OF LICENSING PROGRAM MANAGER: Victoria Bertozzi
NAME OF LICENSING PROGRAM ANALYST: Caitlynn Felias
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 07/10/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/10/2026
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
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME: GARDEN HOME
FACILITY NUMBER: 216803663
VISIT DATE: 07/10/2026
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Continued from LIC809

an adequate supply of emergency water accessible in the event they needed to shelter in place for 72 hours. LPA reviewed staff files, resident files, resident medication. All files were all found to be well organized, thorough and contained the required documentation. Staff files had current First Aid and CPR certification. Resident files had updated resident assessments and appraisals. LPA observed that facility tracks staff annual training by using a training checklist. LPA, Licensee, and Administrator discussed their annual training checklist and ensuring it is fully completed with signatures and dates by a staff member's date of hire.

LPA discussed with Licensee and Administrator on ensuring that resident appraisals address behavioral expressions if they have been identified in resident medical assessments. During medication review it was observed that the pharmacy sends a completed LIC622/Central Storage Log to the facility. It was observed that there was incorrect information on the LIC622 from the pharmacy such as expiration date and number of refills. LPA, Licensee, and Administrator discussed reviewing the LIC622 completed by pharmacy to ensure its accuracy.

LPA also discussed the following with Licensee and Administrator:
  • Reporting Requirements
  • PIN regarding 911 protocols

LPA requested the following documents to update facility file:
  • Designation of Facility Responsibility (LIC 308)
  • Emergency Disaster Plan (LIC 610E)
  • Updated Personnel Report (LIC 500)
  • Updated Liability Insurance
  • Active and Current Administrator Certificate

Documents to be submitted to Community Care Licensing (CCL) by due date of 8/10/2026.

Deficiencies are cited from the California Code of Regulations (CCRs), and/or the Health and Safety Code. Failure to correct the cited deficiencies, on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

Exit interview conducted. Copy of report, LIC809D (Deficiency Page), LIC9102 (Technical Advisories/Violations), Plan of Corrections, and Appeal Rights discussed and provided to Licensee and Administrator. Signature on form confirms receipt of documents.

NAME OF LICENSING PROGRAM MANAGER: Victoria Bertozzi
NAME OF LICENSING PROGRAM ANALYST: Caitlynn Felias
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 07/10/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/10/2026
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 07/10/2026 01:36 PM - It Cannot Be Edited


Created By: Caitlynn Felias On 07/10/2026 at 01:13 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: GARDEN HOME
FACILITY NUMBER: 216803663

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/10/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87555(a)
General Food Service Requirements
(a) The total daily diet shall be of the quality and in the quantity necessary to meet the needs of the residents an shall meet the Recommended Dietary Allowances of the Food and Nutrition Board of the National Research Council. All food shall be selected, stored, prepared and served in a safe and healthful manner.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observations made, Licensee did not comply with the section cited above. Multiple instances of expired foods were observed in facility's refrigerator and freezer including expired tofu and Costco prepared meals. This poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/20/2026
Plan of Correction
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Licensee to submit a written plan on how they will ensure that facility food's expiration date is checked periodically to ensure it is still safe to consume. Plan to be submitted to Community Care Licensing (CCL) by POC due date of 07/20/2026.
Type B
Section Cited
HSC
1569.695(a)(2)
Other Provisions
(a)In addition to any other requirement of this chapter, a residential care facility for the elderly shall have an emergency and disaster plan that shall include, but not be limited to, all of the following: (2) Plans for the facility to be self-reliant for a period of not less than 72 hours immediately following any emergency or disaster, including, but not limited to, a short-term or long-term power failure. If the facility plans to shelter in place and one or more utilities, including water, sewer, gas, or electricity, is not available, the facility shall have a plan and supplies available to provide alternative resources during an outage.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observations made, Licensee did not comply with the section cited above and did not ensure that there was adequate emergency water supply in the event the facility had to shelter in place for at least 72 hours. This poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/20/2026
Plan of Correction
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Licensee to obtain needed emergency supplies and submit proof in the form of photos and/or receipts by POC due date of 07/20/2026.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Victoria Bertozzi
NAME OF LICENSING PROGRAM MANAGER:
Caitlynn Felias
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 07/10/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/10/2026


LIC809 (FAS) - (06/04)
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