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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 216803863
Report Date: 10/30/2025
Date Signed: 10/30/2025 01:44:03 PM

Document Has Been Signed on 10/30/2025 01:44 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:TENDER RESIDENTIAL HOMEFACILITY NUMBER:
216803863
ADMINISTRATOR/
DIRECTOR:		NDOMO, RODRIGUEFACILITY TYPE:
737
ADDRESS:257 BLACKSTONE DRIVETELEPHONE:
(628) 253-5468
CITY:SAN RAFAELSTATE: CAZIP CODE:
94903
CAPACITY: 3CENSUS: 3DATE:
10/30/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:35 AM
MET WITH:Lead Staff Member, Gustavo Carvajal, and Administrator, Rodrigue NdomoTIME VISIT/
INSPECTION COMPLETED:
02:00 PM
NARRATIVE
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On 10/30/2025 at approximately 09:30AM, Licensing Program Analyst (LPA) Ali Deniz arrived unannounced to conduct 1-Year Required visit of this licensed Adult Residential Facility (ARF). LPA was greeted by Lead Staff Member, Gustavo Carvajal. Administrator, Rodrigue Ndomo, arrived at approximately 10:30AM. The facility currently approved for capacity of 3 clients. Facility also has an approved fire clearance and capacity for 3 non-ambulatory residents. Upon arrival, LPA was informed that there were 3 residents in care and 4 staff members on-site. Facility is a 1 story building with 3 clients bedrooms, 2 bathrooms, and common spaces.

At approximately 10AM, LPA reviewed the Facility's Staff Roster and found that all staff on-site were background cleared and associated to the facility per regulation.

At approximately 10:30AM, LPA and Lead staff member toured the building and grounds which was found to be clean and in good repair. LPA observed all walkways and exits to be unobstructed. All notices that are required to be posted have been posted and are in a highly visible area. LPA observed activity supplies for resident use. The amount of fresh and nonperishable foods is within regulation. Facility kitchen, refrigerators and freezers were clean, and food was stored properly. Toxins are stored in a locked cabinet and under the sink inaccessible to clients in care. Water temperature measured 110.6 degrees F and 112.4 degrees F which is within regulation between 105- and 120-degrees F at faucets accessible to residents. Fire Extinguishers found to be last charged on 16/04/2025 at the time of visit. Carbon Monoxide and smoke detectors were present and in order. There was enough lighting in all common areas, resident rooms, and hallways.
Continued on LIC809-C page...
NAME OF LICENSING PROGRAM MANAGER: Victoria Bertozzi
NAME OF LICENSING PROGRAM ANALYST: Ali Deniz
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 10/30/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/30/2025
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 10/30/2025 01:44 PM - It Cannot Be Edited


Created By: Ali Deniz On 10/30/2025 at 12:53 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: TENDER RESIDENTIAL HOME
FACILITY NUMBER: 216803863

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/30/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Request Denied
Type A
Section Cited
CCR
80075(b)
Health-Related Services
(b) Clients shall be assisted as needed with self-administration of prescription and nonprescription medications.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, Licensee did not comply with the section cited above and did not ensure that C1 received their scheduled prescribed medication as required. This poses an immediate health and safety risk to clients in care.
POC Due Date: 11/01/2025
Plan of Correction
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Administrator to submit self certification stating that training will be conducted in medication administration by POC due date of 11/01/2025. Administrator to submit training to CCL that includes the following: Date, Training Topic, Name/Job Role, and Signatures by POC due date of 11/11/2025.
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.
Victoria Bertozzi
NAME OF LICENSING PROGRAM MANAGER:
Ali Deniz
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 10/30/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/30/2025


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
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME: TENDER RESIDENTIAL HOME
FACILITY NUMBER: 216803863
VISIT DATE: 10/30/2025
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At approximately 11:25PM, LPA reviewed 3 resident records and found all residents have current care plans, signed admission agreements, and physician's report on file. Medication records are thorough and contained physician's orders for each resident. LPA reviewed 4 staff records. 4 of 4 records did contain documentation of health screening and TB results as required. Evidence of current first aid and CPR training were current. LPA was presented with proof of current CPR & 1st Aid certification. Administrator Certificate is for Rodrigue #7017219735 expires 10/02/2027. LPA reviewed client medication, and P&I monies. Medication was observed to be centrally stored and secure. P&I monies were documented, secure and not commingled. All files were all found to be well organized, thorough and contained the required documentation. Facility has supplies enough to operate for more than 72 hours in an emergency. Facility conducted and documented a disaster drill on 09/24/2025.

Updated copies of the following documents were requested for facility file and are to be submitted to CCL by due date of 11/10/2025:
- LIC 308 Designation of Facility Responsibility
- LIC 610 Emergency Disaster Plan (If changed)
- LIC 9020 Register of Facility Client’s/Resident’s
- Copy/Proof of Updated Certificate of Liability Insurance

During the visit LPA followed up on a self-reported incident that was submitted to Community Care Licensing (CCL) on 08/20/2025. Report stated that the facility staff inadvertently oversighted C1's scheduled prescribed medication. Facility made all appropriate notifications per regulation (deficiency cited, LIC809D, regulation 80075(b)).

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

***An immediate civil penalty assessment in the total amount of $250.00 has been issued for a repeat violation of Regulation 80075(b) within a 12 month period. Deficiency last cited on 11/21/2024. (See LIC421FC).***

Exit interview conducted. Copy of report, LIC809D (Deficiency Page), LIC421FC (Civil Penalty), Plan of Corrections, and Appeal Rights discussed and provided to Administrator. Signature on form confirms receipt of documents.t.
NAME OF LICENSING PROGRAM MANAGER: Victoria Bertozzi
NAME OF LICENSING PROGRAM ANALYST: Ali Deniz
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 10/30/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/30/2025
LIC809 (FAS) - (06/04)
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