<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 286803356
Report Date: 10/21/2025
Date Signed: 10/21/2025 04:17:07 PM

Document Has Been Signed on 10/21/2025 04:17 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:CORE ARF GADWALLFACILITY NUMBER:
286803356
ADMINISTRATOR/
DIRECTOR:		DADO,MYLENEFACILITY TYPE:
735
ADDRESS:3 GADWALL COURTTELEPHONE:
(707) 554-4802
CITY:AMERICAN CANYONSTATE: CAZIP CODE:
94503
CAPACITY: 2CENSUS: 0DATE:
10/21/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:45 PM
MET WITH:Douglas Dado, DRPTIME VISIT/
INSPECTION COMPLETED:
04:30 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 12:45 PM, Licensing Program Analyst (LPA) Julie Florio arrived unannounced to conduct a required 1-year annual inspection. LPA was greeted by facility staff. Licensee was contacted via telephone and Designated Responsible Party, Douglas Dado arrived approximately 45 minutes later to conduct inspection with LPA. Facility is an Adult Residential Facility (ARF) with no clients currently in care. Facility is licensed for two (2) non-ambulatory clients and their last client moved in the end of May 2025 due to requiring a higher level of care. Facility is vendored with the North Bay Regional Center (NBRC) and is in the process of accepting a new client.

At approximately 1:45 PM, LPA initiated a tour of the facility with DRP and observed the following: Facility is a two story home, was a comfortable temperature, and passageways were free from obstructions. Water temperature in clients' bathrooms measured within the allowable range of 105 to 120 degrees F per Title 22 regulations. LPA observed hand towels hanging in the clients' bathroom and DRP agrees to ensure facility operates in compliance moving forward. LPA observed a supply of clean linens and paper products available to clients. Clients' bedrooms are located on the first floor of the facility and were inspected and observed to have all of the appropriate furnishings as outlined in regulations. Cabinets and storage areas containing cleaning supplies and other items that could pose a risk were unlocked in at least three (3) instances. DRP agreed to secure the items and ensure the facility is operating in compliance with regulation moving forward. Facility has at least two days of perishable food and one week of non-perishable food. DRP agrees to ensure that facility does not have expired non-perishable food in order to operate in compliance with regulation. Medications were observed centrally stored and locked. There is outdoor space for activities in the backyard.

Continued on LIC809C...
NAME OF LICENSING PROGRAM MANAGER: Bethany Moellers
NAME OF LICENSING PROGRAM ANALYST: Julie Florio
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 10/21/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/21/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 3
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)
Page: 2 of 3
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: CORE ARF GADWALL
FACILITY NUMBER: 286803356
VISIT DATE: 10/21/2025
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
26
27
28
29
30
31
32
Continued from LIC809...

DRP replaced both wood fence gates about five (5) years ago with metal gates that both lock from inside the back yard. LPA will return to regional office to discuss with manager. Facility has games, crafting supplies, and karaoke for client use. LPA was informed that facility has internet access and understands that the facility shall provide an internet access device that is designated for client use in the event that a client does not already have one. Facility telephone was tested an operational during today's inspection. Both client bedrooms have a phones.

Facility's fire extinguishers were observed charged and were last serviced 10/2025. Smoke and Carbon Monoxide detectors were tested and operational during inspection. Facility conducts monthly disaster drills when clients are in care. Since there are not currently clients in care, the most recent drill was conducted 08/2025.

LPA observed facility's infection control plan and emergency disaster plan which was last updated 11/2020. LPA observed a supply of gloves, emergency supplies, a first aid kit, and flashlights for emergency preparedness. DRP states the facility does not have a backup generator.

LPA conducted file review of five (5) staff files. All staff files reviewed contained all the required documents per regulation. Staff have current first aid certificates. Client files, medications, medication records, and P&I were not inspected, because there are not currently any clients in care. Facility has a current bond which expires 08/2026. LPA discussed the required posters per regulation with DRP who agreed to ensure facility operates in compliance moving forward.

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

No deficiencies were cited during inspection.

Exit interview conducted with DRP, whose signature on form confirms receipt od documents.
NAME OF LICENSING PROGRAM MANAGER: Bethany Moellers
NAME OF LICENSING PROGRAM ANALYST: Julie Florio
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 10/21/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/21/2025
LIC809 (FAS) - (06/04)
Page: 3 of 3