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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 480102381
Report Date: 04/16/2025
Date Signed: 04/16/2025 12:10:33 PM

Document Has Been Signed on 04/16/2025 12:10 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:JO-MIL GROUP HOMEFACILITY NUMBER:
480102381
ADMINISTRATOR/
DIRECTOR:		CHERYL DAVIDSONFACILITY TYPE:
735
ADDRESS:143 RUTGERSTELEPHONE:
(707) 553-1581
CITY:VALLEJOSTATE: CAZIP CODE:
94589
CAPACITY: 6CENSUS: 4DATE:
04/16/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:10 AM
MET WITH:Shane Mills, DSP and Cheryl Davidson, AdministratorTIME VISIT/
INSPECTION COMPLETED:
12:20 PM
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At approximately 9:10 AM, Licensing Program Analysts (LPAs) Magdaleno and Cuadra arrived unannounced to conduct a required 1-year annual inspection and were greeted by Shane Mills, DSP. Facility is an Adult Residential Facility (ARF) with four (4) clients in care. LPAs were informed that Client 1 (C1), Client 2 (C2), and Client 3 (C3) were away at Day Program and Client 4 (C4) was at work. Facility is serviced by vendor North Bay Regional Center (NBRC). Administrator was contacted at around 11:00 AM

At approximately 9:30 AM, LPAs initiated a tour of the facility with DSP and observed the following: Facility is a one (1) story home, was a comfortable temperature, and passageways were free from obstructions. Facility's fire extinguisher was observed charged and last serviced 3/24. Smoke and Carbon Monoxide detectors were tested and operational during inspection. Water temperatures in client bathrooms read at 142.5 degrees F and 140 degrees F which is not within the allowable range of 105 to 120 degrees F per Title 22 regulations (Deficiency cited). LPAs observed a supply of clean linens, hygiene, and paper products available for clients. Clients' 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 (2) days of perishable food and seven (7) days of non-perishable foods. Facility has an internet access devise and internet available to clients in care, and the phone was tested and operational during today's inspection. There is a seating area in the backyard with outdoor space for activities. LPA observed a supply of PPE, emergency supplies, a first aid kit, and flashlights for emergency preparedness.

Continued on LIC809C...
NAME OF LICENSING PROGRAM MANAGER: Victoria Bertozzi
NAME OF LICENSING PROGRAM ANALYST: Elias Magdaleno
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 04/08/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/08/2025
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 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: JO-MIL GROUP HOME
FACILITY NUMBER: 480102381
VISIT DATE: 04/16/2025
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Continued from LIC809...

Facility conducts monthly disaster drills, and the most recent drill was conducted 3/15/2025. LPA observed facility's infection control plan and emergency disaster plan which was last updated 1/25.

At approximately 10:40 AM LPA conducted a review of four (4) resident records. All required documentation present.

At approximately 11:15 AM LPA conducted review of two (2) staff records. All required documentation present.

At approximately 11:40 AM LPA and DSP conducted a spot check of medication and medication records. Medication is centrally stored and locked.

Facility does not handle cash resources.

Administrator Certificate for Cheryl Davidson certificate number 7011528735 expires 5/15/2026.

Updated copies of the following documents are to be submitted to CCL within 30 days of this visit:

LIC500 - Personnel Report
LIC308 - Designation of Responsibility
LIC400 - Affidavit Regarding Client Cash Resources

Deficiencies are cited from the California Code of Regulations, Title 22, Division 6 of California Regulation and the Health and Safety Code. Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, or repeat violations within a 12-month period, may result in a civil penalty assessment. Appeal rights were provided.

Exit interview conducted with Administrator, whose signature on form confirms receipt.

NAME OF LICENSING PROGRAM MANAGER: Victoria Bertozzi
NAME OF LICENSING PROGRAM ANALYST: Elias Magdaleno
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 04/16/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/16/2025
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 04/16/2025 12:10 PM - It Cannot Be Edited


Created By: Elias Magdaleno On 04/16/2025 at 11:58 AM
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: JO-MIL GROUP HOME
FACILITY NUMBER: 480102381

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/16/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80088(e)(1)
Fixtures, Furniture, Equipment, and Supplies
(e) Faucets used by clients for personal care such as shaving and grooming shall deliver hot water. (1) Hot water temperature controls shall be maintained to automatically regulate temperature of hot water delivered to plumbing fixtures used by clients to attain a hot water temperature of not less than 105 degrees F (40.5 degrees C) and not more than 120 degrees F (48.8 degrees C).

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 two (2) out of two (2) sinks delivered water above 140 degrees which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 04/17/2025
Plan of Correction
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Licensee to self-submit statement that water has been lowered by Plan of Correction (POC). Licensee also to maintain and submit a five (5) day water log.
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:
Elias Magdaleno
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 04/16/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/16/2025


LIC809 (FAS) - (06/04)
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