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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 286804257
Report Date: 08/06/2026
Date Signed: 08/06/2026 03:29:58 PM

Document Has Been Signed on 08/06/2026 03:29 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:AMORVIDA GUEST HOUSEFACILITY NUMBER:
286804257
ADMINISTRATOR/
DIRECTOR:		VIBAT, DAVID CERVANTESFACILITY TYPE:
740
ADDRESS:3552 JEFFERSON STTELEPHONE:
(707) 319-0674
CITY:NAPASTATE: CAZIP CODE:
94558
CAPACITY: 6CENSUS: 5DATE:
08/06/2026
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:00 AM
MET WITH:Claribel Kemper, Designated Responsible PartyTIME VISIT/
INSPECTION COMPLETED:
04:00 PM
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At approximately 10:00 AM, Licensing Program Analyst (LPA) Julie Florio arrived unannounced to conduct a required 1-year annual inspection and met with Claribel Kemper, Designated Responsible Party (DRP). Administrator was contacted via telephone and was unable to attend today's inspection. Facility is a Residential Care Facility for the Elderly (RCFE) with 5 residents in care. Facility is approved for 6 ambulatory residents and has a Hospice waiver for 2.

At approximately 10:25 AM, LPA initiated a tour of the facility with DRP and observed the following: Facility is a on story building, was a comfortable temperature, and passageways were observed free from obstructions. Facility has the required postings in the main common areas which are accessible to the public. 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 paper, incontinent care, and hygiene products available for residents. Residents' bedrooms were inspected and observed to have all the appropriate furnishings as outlined in regulations. Closets containing cleaning supplies and other items that could potentially pose a risk to residents in care were observed locked. LPA observed two instances where egress devices were not activated or in working order. DRP ordered replacement devices immediately and agreed to ensure operational compliance with regulations moving forward. Facility has at least two days of perishable food and one week of non-perishable foods, as well as an emergency water supply. Medications were observed centrally stored and locked. There are outdoor shaded seating areas with space for activities. LPA observed residents engaged in activities in common areas. Facility has internet service and an internet access device designated for resident use. Sprinklers and smoke and carbon monoxide detectors were tested and operational during facility's last fire inspection which was conducted 02/2026.

Continued on LIC809C...
Bethany Moellers
Julie Florio
DATE: 08/06/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/06/2026
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 7
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: AMORVIDA GUEST HOUSE
FACILITY NUMBER: 286804257
VISIT DATE: 08/06/2026
NARRATIVE
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Continued from LIC809C...

Fire extinguishers were observed fully charged and were last inspected 10/2025. Emergency disaster plan was reviewed and updated 10/2025. Facility DRP states that facility conducts biannual disaster drills and was unable to provide proof of any drills having been conducted since licensure, (see LIC809D). LPA informed DRP that drills shall be conducted on each shift no less than quarterly. Facility has a back up generator for emergency preparedness. Facility has emergency lighting and a first aid kit.

At approximately 11:30 AM, LPA conducted file review of three (3) staff files. Two (2) of three (3) staff files reviewed were observed missing proof of both the required annual and required annual medication training hours, (see LIC809Ds). Additionally, one (1) of three (3) staff files reviewed were observed missing the required proof of health screening. DRP scheduled the staff member for a health screening appointment during today's visit and agreed to ensure facility operates in compliance with regulation moving forward. All staff files reviewed contained proof of current FA and CPR certifications and all of the remaining required documents.

At approximately 12:30 PM, LPA conducted file review of five (5) resident files. Four (4) of five (5) resident files reviewed were observed missing one (1) or more of the required documents, (see LIC809D). During today's inspection LPA observed two non-ambulatory residents, Resident 2 (R2) and Resident 3 (R3) in care. The facility's current sketch and fire clearance dated 04/25/2025 do not grant approval for any non-ambulatory residents. The facility does have two resident rooms with sliding glass doors and ramp access. LPA advised DRP to submit a new facility sketch to the Department with a request for a new fire clearance for non ambulatory approval.

At approximately 2:30 PM, LPA reviewed medications and medication records which were observed stored and maintained in compliance with regulation.

Residents' families mostly coordinate medical and dental appointments as well as transportation to and from appointments but facility will assist as needed and utilizes a third party transportation service when indicated. Facility does not handle P&I cash resources. DRP states that Licensee is in the process of purchasing the facility and agrees to submit a copy of the Deed to the Department for proof of control of property.

Continued on LIC809C...
NAME OF LICENSING PROGRAM MANAGER: Bethany Moellers
NAME OF LICENSING PROGRAM ANALYST: Julie Florio
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 08/06/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/06/2026
LIC809 (FAS) - (06/04)
Page: 3 of 7
Document Has Been Signed on 08/06/2026 03:29 PM - It Cannot Be Edited


Created By: Julie Florio On 08/06/2026 at 02:43 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: AMORVIDA GUEST HOUSE
FACILITY NUMBER: 286804257

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/06/2026

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 record review, the licensee did not comply with the section cited above in 2 out of 3 staff files reviewed and were observed missing proof of all of the required annual training hours which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/07/2026
Plan of Correction
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Licensee to submit proof of all of the required annual training hours completed by both Staff 2 (S2) and Staff 3 (S3) as well as a self-certifiation which states that all staff have completed the required annual training hours to CCL by POC due date 09/07/2026.
Type B
Section Cited
HSC
1569.69(b)
Other Provisions
(b) Each employee who received training and passed the examination required in paragraph (5) of subdivision (a), and who continues to assist with the self-administration of medicines, shall also complete eight hours of in-service training on medication-related issues in each succeeding 12-month period.

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 out of 3 staff files reviewed and were observed missing proof of all of the reuired annual medication training hours which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/07/2026
Plan of Correction
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Licensee to submit proof of all of the required annual medication training hours completed by both Staff 2 (S2) and Staff 3 (S3) as well as a self-certifiation which states that all who assist with medication administration have completed the required annual training hours to CCL by POC due date 09/07/2026.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Bethany Moellers
NAME OF LICENSING PROGRAM MANAGER:
Julie Florio
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 08/06/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/06/2026


LIC809 (FAS) - (06/04)
Page: 4 of 7
Document Has Been Signed on 08/06/2026 03:29 PM - It Cannot Be Edited


Created By: Julie Florio On 08/06/2026 at 02:43 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: AMORVIDA GUEST HOUSE
FACILITY NUMBER: 286804257

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/06/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87506(a)
Resident Records
(a) The licensee shall ensure that a separate, complete, and current record is maintained for each resident in the facility or in a central administrative location readily available to facility staff and to licensing agency staff.

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 4 out of 5 resident files reviewed where each was observed missing one or more of the required documents which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/07/2026
Plan of Correction
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Licensee to submit a self certification that all resident files have all of the documents required per regulation to CCL by POC due date of 09/07/2026.
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
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Based on record review, the licensee did not comply with the section cited above by not being able to produce any logs or proof that any emergency drills have been conducted within hte last year which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/07/2026
Plan of Correction
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Licensee to submit proof that an emegency drill has been conducted and self-certification that they understand and agree to comply with regulation which requiers a drill be conducted on every shift no less than quarterly to CCL by POC due date of 09/07/2026.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Bethany Moellers
NAME OF LICENSING PROGRAM MANAGER:
Julie Florio
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 08/06/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/06/2026


LIC809 (FAS) - (06/04)
Page: 5 of 7
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: AMORVIDA GUEST HOUSE
FACILITY NUMBER: 286804257
VISIT DATE: 08/06/2026
NARRATIVE
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Continued from LIC809C...

Updated copies of the following documents are to be submitted to CCL within 30 days of this visit:
  • LIC500 - Personnel Roster (updated to include administrator's schedule)
  • LIC610E Emergency Disaster Plan (updated)
  • Facility Sketch (updated)

Deficiencies are being cited from the California Code of Regulations, Title 22, Division 6 of California Regulation and the Health and Safety Code. Failure to correct the deficiencies by the plan of correction date and/or repeat deficiencies within a 12 month period may result in civil penalties.

Exit interview conducted with DRP, whose signature on form confirms receipt of this report.

NAME OF LICENSING PROGRAM MANAGER: Bethany Moellers
NAME OF LICENSING PROGRAM ANALYST: Julie Florio
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 08/06/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/06/2026
LIC809 (FAS) - (06/04)
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