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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 236804284
Report Date: 03/09/2026
Date Signed: 03/09/2026 02:29:58 PM

Document Has Been Signed on 03/09/2026 02:29 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:HARMONY ONE CARE HOMEFACILITY NUMBER:
236804284
ADMINISTRATOR/
DIRECTOR:		WONG, STANLEYFACILITY TYPE:
740
ADDRESS:512 CANYON VIEW CTTELEPHONE:
(707) 380-7494
CITY:UKIAHSTATE: CAZIP CODE:
95482
CAPACITY: 7CENSUS: 7DATE:
03/09/2026
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:15 AM
MET WITH:Will PraiphetsakTIME VISIT/
INSPECTION COMPLETED:
02:45 PM
NARRATIVE
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At approximately 8:15AM, Licensing Program Analyst (LPA) Chris Arnhold made an unannounced annual required inspection of this licensed senior care facility. LPA met with House Manager Will Praiphetsak. At approximately 8:45AM, LPA toured the building and grounds which was found to be clean and orderly. LPA observed the back deck ramp has a potential trip hazard at the base, where the boards are raised and the concrete is crumbling. The emergency exit gate was observed to be tied closed with string, preventing it from being opened. This is a repeat violation within a 12 month period. An immediate civil penalty is being issued in the amount of $1000. 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 storage closet. Water temperature measured within regulation between 105 and 120 degrees F at faucets accessible to residents. Fire extinguishers inspected were charged. Smoke detectors in the living room, hallway and one residents room had their batteries disconnected. This is an immediate Safety risk to residents in care. An immediate civil penalty is being issued in the amount of $500. Staff replaced batteries during visit and alarms were functional. Carbon Monoxide detectors were present. There was enough lighting in all common areas, resident rooms, and hallways. Most medication is centrally stored and secure, however, a bottle of vitamins was stored in the dining room cupboard, which is easily accessible. LPA observed cleaning solutions stored, unsecured, under each of the two resident bathroom sinks.
At approximately 9:00AM, LPA reviewed 7 of 7 resident records and found 3 of 7 residents have not had a physician visit within the last 12 months. LPA observed 2 of 7 residents did not have current appraisals during this visit. LPA spoke with Licensee about physician reports and the requirements of when they need to be updated during the Post Licensing visit on 07/07/2025. LPA provided copies of regulation pertaining to resident records and incidental medical topics during that visit and issued a technical violation at the time. LPA reviewed medication records and observed there were no centrally stored medication lists for any resident. Medication was prepared for the day in small containers. Continued on LIC 809-C...
NAME OF LICENSING PROGRAM MANAGER: Kimberley Mota
NAME OF LICENSING PROGRAM ANALYST: Christopher Arnhold
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 03/09/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/09/2026
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: HARMONY ONE CARE HOME
FACILITY NUMBER: 236804284
VISIT DATE: 03/09/2026
NARRATIVE
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LPA observed one pill container from the AM medication pass still contained pills. After breakfast, R1 went back to sleep and did not take morning medication. Staff did not notify residents physician, and were going to give the medication when they woke. LPA provided instruction on medication time frames and reporting.

At approximately 11:15AM, LPA was not able to review staff records as they were not present at the facility. This is a repeat violation in a 12 month period. An immediate civil penalty is being issued in the amount of $250. Evidence of current first aid and CPR training were current. LPA interviewed 2 staff during this inspection.

At approximately 12:00PM, LPA reviewed facility disaster plan. Staff did not appear to have a good understanding of disaster procedures and what to do in an emergency. House manager was able demonstrate where gas and water shutoffs were and how to operate. LPA reviewed the emergency drill log and found the last drill was conducted 07/24/2025. This is a repeat violation within in a 12 month period. An immediate civil penalty is being issued in the amount of $250.

Updated copies of the following documents were requested for facility file and are to be submitted to CCL within 30 days of this visit:
Evidence of control of Property, (Current Rental/Lease Agreement/Deed)
LIC308- Designation of Facility Responsibility
LIC500- Personnel Report
LIC610E- Disaster Plan
Updated Facility Sketch showing Ambulatory status of each room
Evidence of Liability Insurance


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.

This report was reviewed with Will Praiphetsak and Appeal rights were given.
NAME OF LICENSING PROGRAM MANAGER: Kimberley Mota
NAME OF LICENSING PROGRAM ANALYST: Christopher Arnhold
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 03/09/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/09/2026
LIC809 (FAS) - (06/04)
Page: 3 of 18
Document Has Been Signed on 03/09/2026 02:29 PM - It Cannot Be Edited


Created By: Christopher Arnhold On 03/09/2026 at 12:56 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: HARMONY ONE CARE HOME
FACILITY NUMBER: 236804284

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/09/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87307(d)(6)
Personal Accommodations and Services
(6) All outdoor and indoor passageways and stairways shall be kept free of obstruction.

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. The emergency exit gate was tied closed, preventing exiting in an emergency, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 03/10/2026
Plan of Correction
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Licensee agrees to fix the latch on the gate and submit photo evidence of completion by 03/10/2026.
Type A
Section Cited
CCR
87309(a)
Storage Space and Access
(a) Except as specified in subsection (b), the licensee shall ensure that disinfectants, cleaning solutions, poisonous substances, knives, matches, tools, sharp objects, and other similar items which could pose a danger to residents are in locked storage and are not left unattended if outside the locked storage.

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 of 2 resident bathrooms. Cleaning products were stored under the sink and the cabinet doors were not secure, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 03/10/2026
Plan of Correction
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Licensee agrees to keep cleaning solutions in areas no accessible to residents. Cleaning solutions were relocated to a secure location during visit. 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.
Kimberley Mota
NAME OF LICENSING PROGRAM MANAGER:
Christopher Arnhold
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 03/09/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/09/2026


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 03/09/2026 02:29 PM - It Cannot Be Edited


Created By: Christopher Arnhold On 03/09/2026 at 12:56 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: HARMONY ONE CARE HOME
FACILITY NUMBER: 236804284

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/09/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87465(e)
Incidental Medical and Dental Care Services
(e) For every prescription and nonprescription PRN medication for which the licensee provides assistance there shall be a signed, dated written order from a physician on a prescription blank, maintained in the resident's file, and a label on the medication. Both the physician's order and the label shall contain at least all of the following information.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in 5 of 7 resident records. Records did not contain physician orders for medications, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 03/10/2026
Plan of Correction
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Licensee agrees to contact each resident physician and get orders for each medication. Self Certification that each residents physician has been contacted, shall be sent to CCLD by 03/10/2026.
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.
Kimberley Mota
NAME OF LICENSING PROGRAM MANAGER:
Christopher Arnhold
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 03/09/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/09/2026


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 03/09/2026 02:29 PM - It Cannot Be Edited


Created By: Christopher Arnhold On 03/09/2026 at 12:56 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: HARMONY ONE CARE HOME
FACILITY NUMBER: 236804284

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/09/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.625(b)(2)
Other Provisions
(2) In addition to paragraph (1), training requirements shall also include an additional 20 hours annually, eight hours of which shall be dementia care training, as required by subdivision (a) of Section 1569.626, and four hours of which shall be specific to postural supports, restricted health conditions, and hospice care, as required by subdivision (a) of Section 1569.696. This training shall be administered on the job, or in a classroom setting, or both, and may include online training.

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. Personnel records were not maintained at the facility for all staff. This poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/27/2026
Plan of Correction
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Licensee agrees to ensure staff records are maintained for all staff and kept at the facility for review. Licensee agrees to submit self certification that all staff have a personnel record at the facility. Self certification shall be submitted to CCL by 03/27/2026.
Type B
Section Cited
CCR
87555(b)(23)
General Food Service Requirements
(23) All readily perishable foods or beverages capable of supporting rapid and progressive growth of micro-organisms which can cause food infections or food intoxications shall be stored in covered containers at appropriate temperatures.

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. Left over food was stored in the garage refrigerator, uncovered with other food stores, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/27/2026
Plan of Correction
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Licensee agrees that all food shall be stored appropriately to prevent food born illnesses. Self certification that all food is stored appropriately shall be submitted to CCL by 03/27/2026.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Kimberley Mota
NAME OF LICENSING PROGRAM MANAGER:
Christopher Arnhold
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 03/09/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/09/2026


LIC809 (FAS) - (06/04)
Page: 6 of 18
Document Has Been Signed on 03/09/2026 02:29 PM - It Cannot Be Edited


Created By: Christopher Arnhold On 03/09/2026 at 12:56 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: HARMONY ONE CARE HOME
FACILITY NUMBER: 236804284

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/09/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87465(h)(5)
Incidental Medical and Dental Care Services
(h) The following requirements shall apply to medications which are centrally stored: (5) Each resident's medication shall be stored in its originally received container. No medications shall be transferred between containers.

This requirement is not met as evidenced by:
Deficient Practice Statement
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4
Based on observation, the licensee did not comply with the section cited above in 7 of 7 residents. Medications were prepared, in advance, for the day for 7 of 7 residents, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/27/2026
Plan of Correction
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Licensee agrees that medication will be stored in the original container until the prescribed time. Licensee shall submit self certification that all medications will be stored in original containers until the prescribed time by 03/27/2026.
Type B
Section Cited
CCR
87463(a)
Reappraisals
(a) The pre-admission appraisal, as specified in Section 87457, Pre-Admission Appraisal, shall be updated, in writing as frequently as necessary or once every 12 months, whichever occurs first, to note significant changes in condition, as defined in Section 87101, Definitions, and to keep the appraisal accurate. For the purposes of this section, the updated pre-admission appraisal shall be referred to as the reappraisal.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in 2 of 7 resident records. Records did not contain current reappraisals, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/27/2026
Plan of Correction
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Licensee agrees to ensure residents receive reappraisals at least every 12 months or more often as necessary. Self certification of completed reappraisals shall be submitted to CCLD by 03/27/2026.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Kimberley Mota
NAME OF LICENSING PROGRAM MANAGER:
Christopher Arnhold
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 03/09/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/09/2026


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 03/09/2026 02:29 PM - It Cannot Be Edited


Created By: Christopher Arnhold On 03/09/2026 at 12:56 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: HARMONY ONE CARE HOME
FACILITY NUMBER: 236804284

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/09/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87463(h)
Reappraisals
(h) The licensee shall request that all residents receive an annual routine visit with a licensed medical professional once every twelve months, either in person or by video appointment.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review, the licensee did not comply with the section cited above in 3 of 7 resident records. Records did not contain evidence of a visit or refusal, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/27/2026
Plan of Correction
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2
3
4
Licensee agrees to ensure all residents are seen by a medical professional at least every 12 months or document their refusal. Licensee agrees to submit self certification that Licensee understands and will document resident refusals.
Self certification shall be submitted to CCLD by 03/27/2026.
Type B
Section Cited
HSC
1569.695(c)
Other Provisions
(c) A facility shall conduct a drill at least quarterly for each shift. The type of emergency covered in a drill shall vary from quarter to quarter, taking into account different emergency scenarios. An actual evacuation of residents is not required during a drill. While a facility may provide an opportunity for residents to participate in a drill, it shall not require any resident participation. Documentation of the drills shall include the date, the type of emergency covered by the drill, and the names of staff participating in the drill.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review, the licensee did not comply with the section cited above. Facility has not documented a completed drill since 07/24/2025, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/27/2026
Plan of Correction
1
2
3
4
Licensee agrees to conduct and document an emergency drill quarterly and submit self certification of completed drill. Self certification shall be submitted to CCLD by 03/27/2026.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Kimberley Mota
NAME OF LICENSING PROGRAM MANAGER:
Christopher Arnhold
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 03/09/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/09/2026


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 03/09/2026 02:29 PM - It Cannot Be Edited


Created By: Christopher Arnhold On 03/09/2026 at 01:52 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: HARMONY ONE CARE HOME
FACILITY NUMBER: 236804284

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/09/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87303(a)
Maintenance and Operation
(a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, the licensee did not comply with the section cited above. Three smoke detectors, living room, hallway and 1 resident room, had their batteries disconnected, preventing them from working in an emergency. This poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 03/10/2026
Plan of Correction
1
2
3
4
Licensee agrees to ensure all smoke detectors are in working order and to replace them as necessary. Batteries were installed and tested for proper operation. Cleared during visit.
Section Cited
Deficient Practice Statement
1
2
3
4
POC Due Date:
Plan of Correction
1
2
3
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.
Kimberley Mota
NAME OF LICENSING PROGRAM MANAGER:
Christopher Arnhold
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 03/09/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/09/2026


LIC809 (FAS) - (06/04)
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