286800667-11-7-2025-21-AS-JFLO-DN7W5K-20251107155916

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 286800667
Report Date: 11/07/2025
Date Signed: 11/07/2025 03:59:24 PM

Document Has Been Signed on 11/07/2025 03:59 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:	CEDARS CARE HOME, THE		FACILITY NUMBER:	286800667
ADMINISTRATOR/ DIRECTOR:	JUSTIN HEROLD		FACILITY TYPE:	740
ADDRESS:	1520 CEDAR STREET		TELEPHONE:	(707) 942-9200
CITY:	CALISTOGA	STATE: CA	ZIP CODE:	94515
CAPACITY: 12		CENSUS: 7	DATE:	11/07/2025
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	10:00 AM
MET WITH:	Justin Herold, Administrator		TIME VISIT/ INSPECTION COMPLETED:	04:15 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	At approximately 10:00 AM, Licensing Program Analysts (LPA) Julie Florio arrived unannounced to conduct a required 1-year annual inspection and was greeted by Justin Herold, Administrator. Facility is a Residential Care Facility for the Elderly (RCFE) with seven (7) residents in care. Facility has a Dementia Care Plan, a Hospice waiver for four (4), with three (3) Hospice residents currently in care, and is approved for all non-ambulatory residents. At approximately 11:00 AM, LPA initiated a tour of the facility with Administrator and observed the following: Facility is a one story home, was a comfortable temperature, and passageways were free from obstructions. Water temperatures in residents' bathrooms measured within the allowable range of 105 to 120 degrees F per Title 22 regulations. LPA observed a supply of clean linens, and hygiene, incontinent care, and paper products available for residents. Residents' bedrooms were inspected and observed to have all the appropriate furnishings as outlined in Title 22 regulations. Cabinets containing cleaning supplies and other items that could pose a risk were locked. Facility has at least two days of perishable food and LPA informed Administrator of the requirement to maintain one week of non-perishable foods. Administrator agrees to bring the facility into compliance immediately, as well as obtain an emergency supply of water. Medications were centrally stored and locked. There is a shaded seating area in the backyard with outdoor space for activities. LPA observed two locked sheds in the backyard. LPA inspected and observed the contents of one consisting of furniture, resident care equipment, tools, and holiday decorations. LPA inspected and observed the contents of the second one containing a water tank which is not currently being used. LPA observed backyard gates all secured with bolt lock. Continued on LIC809-C...

NAME OF LICENSING PROGRAM MANAGER: Bethany Moellers
NAME OF LICENSING PROGRAM ANALYST: Julie Florio
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 11/07/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/07/2025

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
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: CEDARS CARE HOME, THE	FACILITY NUMBER: 286800667
	VISIT DATE: 11/07/2025

NARRATIVE

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Administrator states the fire department will be at facility next week and Administrator will consult with them about which ones need to be changed to latch locks in order to operate in compliance with fire code.

LPA observed a piano, book shelves full of books, puzzles, and crafting supplies in the living room off of the main entrance. LPA observed residents enjoying live music during today's inspection. LPA was informed that the facility plans to develop more routine activities. Facility has internet access and Administrator agrees to ensure an internet access device is designated for resident use. Facility telephone was tested an operational during inspection.

Facility has five (5) fire extinguishers which were observed charged and were last serviced 01/2025. Smoke and Carbon Monoxide detectors were tested and operational during inspection. Facility recently changed administrators and disaster drill logs were not available. Administrator states that facility will conduct an Lastly, emergency disaster drill next week and understands that drills shall be conducted no less than quarterly to remain in compliance with regulation. LPA observed the facility's infection control plan, first aid kit, PPE, flashlights, and emergency supplies. Administrator states facility has a generator for emergency preparedness. LPA reviewed facility's emergency disaster plan last updated 1/2024.

At approximately 1:00 PM, LPA conducted file review. Four (4) staff and four (4) residents' files were reviewed and LPA observed the following: Three (3) of four (4) staff files reviewed were missing proof of both initial and annual training to include medication training. Administrator states that with change of leadership documents are incomplete or lacking from files. LPA provided Administrator with Health and Safety Code sections which detail the training requirements and Administrator agrees to being the facility into compliance immediately. Additionally, two (2) of four (4) staff files were missing proof of current CPR and First Aid training certification. Administrator agrees to ensure all staff receive proof of certification immediately. Lastly, two (2) of four (4) staff files reviewed were missing the required health screenings with proof of negative TB results. Administrator agrees to being the facility into compliance immediately. Four (4) of four (4) resident files reviewed were observed missing current needs and services plans which Administrator agrees to complete and review with the residents' responsible parties immediately.

Continued on LIC809C...

NAME OF LICENSING PROGRAM MANAGER: Bethany Moellers
NAME OF LICENSING PROGRAM ANALYST: Julie Florio
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 11/07/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/07/2025

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: CEDARS CARE HOME, THE	FACILITY NUMBER: 286800667
	VISIT DATE: 11/07/2025

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Lastly, two (2) of two (2) resident files reviewed were observed missing the required consent forms, which Administrator agrees to obtain and ensure all are present in resident files moving forward. LPA discussed the requirement that all staff and resident records are current and present in the files. Administrator agreed to ensure the facility is operating within compliance at all times moving forward. .

At approximately 3:00 PM, LPA reviewed medications and medication records which are maintained and stored in compliance with regulation.

Administrator states that the residents families coordinate residents' medical and dental appointments and transportation to and from visits. However, Administrator also states that facility will assist with coordinating these appointments and transportation for residents upon request. Facility does not manage P&I.

LPA discussed the Department's Technical Support Program (TSP) with Administrator who has agreed to utilize this service. LPA will submit a referral for Administrator.

Administrator had to leave at 3:15 and gave permission for a designated responsible party (DRP), staff Norma Rodriguez to sign today's visit report.

Updated copies of the following documents are to be submitted to CCL within 30 days of this visit:
-LIC610E - Emergency Disaster Plan (updated)
-LIC500 Personnel Report (updated)

No deficiencies were cited during today's inspection.

Exit interview conducted with DRP whose signature on form confirms receipt.

NAME OF LICENSING PROGRAM MANAGER: Bethany Moellers
NAME OF LICENSING PROGRAM ANALYST: Julie Florio
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 11/07/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/07/2025

LIC809 (FAS) - (06/04)

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